Management of Antithrombotic-Related Intracerebral Hemorrhage
Even though hemorrhagic stroke is less common than ischemic stroke, the former is generally associated with worse clinical outcomes. Intracerebral hemorrhage (ICH) is a key type of hemorrhagic stroke, with a variety of important causes including antithrom
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Tarun Girotra, Wuwei Feng, and Bruce Ovbiagele
14.1 Epidemiology 14.1.1 Incidence Intracerebral hemorrhage (ICH) accounts for about 10–20% of all strokes worldwide. The overall global annual incidence of ICH is estimated to be 24.6 per 100,000 (95% CI 19.7–30.7) [1]. Ethnic differences in incidence of ICH are striking. The annual incidence of ICH is 48.9 per 100,000 in black population and 26.6 per 100,000 population in white population [2]. Hispanics have also been observed to have a greater risk of ICH compared to non-Hispanic white population (OR 2.6, 95% CI 1.4–6.1) [3]. Asian population appears to be at a greater risk of ICH compared to other populations. A meta-analysis found that Asian populations have a higher proportion of ICH compared to white populations [28.0% (95% CI 23.6–32.6%) vs. 12.4% (95% CI 10.2– 14.7%)] [4]. Age is another important non-modifiable risk factor for ICH. Population over 85 years of age has an almost tenfold yearly increase in risk of ICH compared to population between 45 and 54 years T. Girotra · W. Feng Medical University of South Carolina, Charleston, SC, USA B. Ovbiagele (*) Department of Neurology, Medical University of South Carolina, Charleston, SC, USA e-mail: [email protected]
of age. Female gender has been associated with lower risk of ICH, although large-scale observation studies have found this to be statistically nonsignificant (RR 0.85, 95% CI 0.61–1.18) [5].
14.1.2 Antithrombotic-Related ICH Long-term use of aspirin has been noted to have an increased risk of ICH compared to placebo with a RR of 1.65 (95% CI 1.05–5.99) per one meta-analysis [6]. AC-related ICH is estimated to be 2–9 cases per 100,000 population/year. This number is expected to rise as the global average life expectancy and the incidence of conditions requiring AC use such as atrial fibrillation increase. The use of warfarin carries a 0.3–3.7% annual risk of ICH. New oral anticoagulants (NOACs) have become more popular in recent years as they have several advantages: fewer interactions with food and other drugs, rapid onset, and freedom from the need to have periodic blood test monitoring and relatively shorter half-life. The rates of major bleedings, GI bleeding, and ICH from the three pivotal trials have been summarized in Table 14.1 [7–10]. Several recent meta-analyses showed that the use of NOACs is associated with a lower risk of ICH compared to warfarin use with RR varying from 0.46 (95% CI 0.33–0.65) to 0.48 (95% CI 0.39– 0.59) [11, 12]. Postmarketing studies have also shown consistent benefit of NOACs in terms of
© Springer Science+Business Media Singapore 2018 S.-H. Lee (ed.), Stroke Revisited: Hemorrhagic Stroke, Stroke Revisited, https://doi.org/10.1007/978-981-10-1427-7_14
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