NOAC-Associated Intracerebral Hemorrhage Linked to Adverse Outcomes

The study did not establish whether early intervention improves outcomes.

Intracerebral hemorrhage related to the use of non-vitamin K antagonist oral anticoagulants (NOAC) is associated with high mortality rates and unfavorable outcomes, according to data published in JAMA Neurology.

For patients on anticoagulants, intracerebral hemorrhage (ICH) is notably the worst possible adverse event, as it is associated with an increased likelihood of brain damage and death.

In the current study, researchers led by Jan C. Purrucker, MD, of Heidelberg University Hospital in Heidelberg, Germany, and colleagues sought to evaluate the clinical course, acute management, and outcomes of ICH related to NOAC use.

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Sixty-one patients with NOAC-associated ICH from 38 stroke units across Germany were included in the study. Forty-one percent (25 of 61) were female, and mean age was 76.1 (11.6) years. At admission, the median NIH Stroke Scale score was 10, and mean baseline hematoma volume was 23.7 (31.3) mL.

Substantial hematoma expansion (measured in 45 patients) occurred in 38% of patients, with new or increased intraventricular hemorrhage observed in 18%.

Fifty-seven percent of total patients received 4-factor prothrombin complex concentrate for anticoagulation reversal. Administration of the blood coagulant had no statistically significant effect on early hematoma expansion and functional outcome at 3 months.

At 3-month follow-up, 17 patients (28%) had died, and 65% of survivors had unfavorable outcomes (modified Rankin Scale score 3-6, median = 4). Oral anticoagulation was resumed in 23% of survivors by 3-month follow-up.

The researchers observed a strong association between clinical deficit at admission and death and dependency at 3 months. Large hematoma volume and intraventricular extension at baseline were also associated with unfavorable outcomes, including death, at 3 months. Notably, no association was found between substantial hematoma expansion and unfavorable outcome.

While it remains to be shown whether reversal of anticoagulation results in improved clinical outcomes, the researchers are now planning a larger prospective study to examine this possible association further.


Purrucker JC, Haas K, Rizos T, et al. Early Clinical and Radiological Course, Management, and Outcome of Intracerebral Hemorrhage Related to New Oral Anticoagulants. JAMA Neurol. 2015; doi: 10.1001/jamaneurol.2015.3682.