From the Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (V.-A.L., M.H.S.).
Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.P., A.K., A.V.A., G.T.).
Stroke. 2018 Oct;49(10):2309-2316. doi: 10.1161/STROKEAHA.118.021979.
Background and Purpose- The aim of this study was to prospectively validate our prior findings of smaller hematoma volume and lesser neurological deficit in nonvitamin K oral anticoagulant (NOAC) compared with Vitamin K antagonist (VKA)-related intracerebral hemorrhage (ICH). Methods- Prospective 12-month observational study in 15 tertiary stroke centers in the United States, Europe, and Asia. Consecutive patients with premorbid modified Rankin Scale score of <2 with acute nontraumatic anticoagulant-related ICH divided into 2 groups according to the type of anticoagulant: NOAC versus VKA. We recorded baseline ICH volume, significant hematoma expansion (absolute [12.5 mL] or relative [>33%] increase), neurological severity measured by National Institutes of Health Stroke Scale score, 90-day mortality, and functional status (modified Rankin Scale score). Results- Our cohort comprised 196 patients, 62 NOAC related (mean age, 75.0±11.4 years; 54.8% men) and 134 VKA related (mean age, 72.3±10.5; 73.1% men). There were no differences in vascular comorbidities, antiplatelet, and statin use; NOAC-related ICH patients had lower median baseline hematoma volume (13.8 [2.5-37.6] versus 19.5 [6.6-52.0] mL; P=0.026) and were less likely to have severe neurological deficits (National Institutes of Health Stroke Scale score of >10 points) on admission (37% versus 55.3%, P=0.025). VKA-ICH were more likely to have significant hematoma expansion (37.4% versus 17%, P=0.008). NOAC pretreatment was independently associated with smaller baseline hematoma volume (standardized linear regression coefficient:-0.415 [95% CI, -0.780 to -0.051]) resulting in lower likelihood of severe neurological deficit (odds ratio, 0.44; 95% CI, 0.22-0.85) in multivariable-adjusted models. Conclusions- Patients with NOAC-related ICH have smaller baseline hematoma volumes and lower odds of severe neurological deficit compared with VKA-related ICH. These findings are important for practicing clinicians making anticoagulation choices.
本研究旨在前瞻性验证我们之前的研究结果，即与维生素 K 拮抗剂（VKA）相关的脑出血（ICH）相比，非维生素 K 口服抗凝剂（NOAC）相关 ICH 的血肿体积更小，神经功能缺损更轻。方法：这是一项在美国、欧洲和亚洲的 15 家三级卒中中心进行的前瞻性 12 个月观察性研究。连续纳入既往改良Rankin 量表评分＜2 的急性非外伤性抗凝相关 ICH 患者，根据抗凝药物类型分为 2 组：NOAC 组与 VKA 组。我们记录了基线时 ICH 体积、显著血肿扩大（绝对[12.5ml]或相对[＞33%]增加）、采用国立卫生研究院卒中量表（NIHSS）评分评估的神经严重程度、90 天死亡率和功能状态（改良 Rankin 量表评分）。结果：本研究队列共纳入 196 例患者，62 例为 NOAC 相关 ICH（平均年龄 75.0±11.4 岁，54.8%为男性），134 例为 VKA 相关 ICH（平均年龄 72.3±10.5 岁，73.1%为男性）。两组患者血管合并症、抗血小板药物和他汀类药物的使用无差异；NOAC 相关 ICH 患者的基线血肿体积中位数更小（13.8[2.5-37.6]ml 比 19.5[6.6-52.0]ml；P=0.026），入院时更可能神经功能缺损较轻（NIHSS 评分＞10 分的患者占 37%比 55.3%，P=0.025）。VKA-ICH 更有可能发生显著血肿扩大（37.4%比 17%，P=0.008）。NOAC 预处理与基线血肿体积较小独立相关（标准化线性回归系数：-0.415[95%CI，-0.780 至-0.051]），多变量调整模型中严重神经功能缺损的可能性降低（比值比，0.44；95%CI，0.22-0.85）。结论：与 VKA 相关 ICH 相比，NOAC 相关 ICH 患者的基线血肿体积更小，严重神经功能缺损的可能性更低。这些发现对临床医生进行抗凝治疗选择具有重要意义。
