Adachi Tomohide, Hoshino Haruhiko, Takagi Makoto, Fujioka Shodo
Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
Department of Neurosurgery, Saiseikai Misumi Hospital, Uki-city, Japan.
Cerebrovasc Dis Extra. 2017;7(1):62-71. doi: 10.1159/000462985. Epub 2017 Apr 3.
Patients undergoing anticoagulation therapy often experience intracerebral hemorrhages (ICHs), and warfarin in particular is known to increase hematoma expansion in ICHs, which results in a poor outcome. Recent studies reported that, in comparison with warfarin, direct oral anticoagulants (DOACs) cause fewer ICHs with better functional outcome. However, since it is still unknown whether DOACs are associated with a smaller hematoma volume of ICHs, we aimed to compare the volume, hematoma expansion, and outcomes associated with ICHs treated with DOACs and warfarin.
We performed a prospective multicenter cross-sectional study. The subjects included patients with acute ICHs who received either DOACs or warfarin. We evaluated the clinical characteristics, and measured initial and follow-up ICH volumes. The volume of ICHs and hematoma expansion were compared between the DOAC and warfarin groups. Mortality and modified Rankin score at discharge were evaluated as outcomes.
There were 18 patients in the DOAC group and 71 in the warfarin group. The baseline characteristics were similar between the 2 groups. Initial median hematoma volume of ICHs in the DOAC group was significantly lower than that in the warfarin group (6.2 vs. 24.2 mL, respectively; p = 0.04). In cases involving follow-up computed tomography scanning, the median hematoma volume of ICHs at follow-up was lower in the DOAC group than in the warfarin group (initial: DOACs 4.4 vs. warfarin 13.5 mL; follow-up: 5.0 vs. 18.4 mL, respectively; p = 0.05). Further, the hematoma in ICHs associated with DOACs did not expand. Although the mortality of ICHs associated with DOACs (11%) was lower than that associated with warfarin (24%), this difference was not statistically significant. The univariate analysis showed that the anticoagulant type (DOACs vs. warfarin) and sex (male vs. female) were associated with ICH volume. The multivariable linear regression showed that the use of DOACs (compared to warfarin; β: -0.23, p = 0.03) and female sex (compared to male; β: -0.25, p = 0.02) were associated with a small hematoma volume.
CONCLUSIONS: Based on the results of the present study, in terms of the risks associated with ICHs, the use of DOACs appears to be safer than warfarin for anticoagulation therapy. Further studies are required to validate these findings. .
接受抗凝治疗的患者常发生脑出血（ICH），尤其是华法林已知会增加脑出血时的血肿扩大，导致预后不良。最近的研究报告称，与华法林相比，直接口服抗凝剂（DOAC）引起的脑出血较少，功能预后更好。然而，由于尚不清楚DOAC是否与较小的脑出血血肿体积相关，我们旨在比较接受DOAC和华法林治疗的ICH的体积、血肿扩大情况及预后。
我们进行了一项前瞻性多中心横断面研究。研究对象包括接受DOAC或华法林治疗的急性ICH患者。我们评估了临床特征，并测量了初始和随访时的ICH体积。比较了DOAC组和华法林组的ICH体积和血肿扩大情况。将出院时的死亡率和改良Rankin评分作为预后指标进行评估。
DOAC组有18例患者，华法林组有71例患者。两组的基线特征相似。DOAC组ICH的初始中位血肿体积显著低于华法林组（分别为6.2 vs. 24.2 mL；p = 0.04）。在进行随访计算机断层扫描的病例中，DOAC组随访时ICH的中位血肿体积低于华法林组（初始：DOAC组4.4 vs.华法林组13.5 mL；随访：分别为5.0 vs. 18.4 mL；p = 0.05）。此外，与DOAC相关的ICH血肿未扩大。虽然与DOAC相关的ICH死亡率（11%）低于与华法林相关的ICH死亡率（24%），但这种差异无统计学意义。单因素分析显示，抗凝剂类型（DOAC与华法林）和性别（男性与女性）与ICH体积相关。多变量线性回归显示，使用DOAC（与华法林相比；β：-0.23，p = 0.03）和女性（与男性相比；β：-0.25，p = 0.02）与较小的血肿体积相关。
基于本研究结果，就与ICH相关的风险而言，在抗凝治疗中使用DOAC似乎比华法林更安全。需要进一步研究来验证这些发现。
