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Re-initiation of anticoagulation after central nervous system hemorrhage during treatment with direct oral anticoagulants: a single hospital cohort study

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Abstract

Background

Central nervous system (CNS) hemorrhage is a serious complication related to direct oral anticoagulant (DOAC) therapy. Current recommendations about re-initiation of anticoagulation treatment are limited to expert opinions. For this purpose, we analyzed the data of all consecutive DOAC patients with CNS hemorrhage, in whom DOACs were reinitiated.

Methods

Over a 6-year period (2012–2018), all consecutive patients with CNS hemorrhage (subdural, subarachnoid, intracerebral, spinal), while receiving DOACs, were included in this observational single-center cohort study. DOAC therapy was reinitiated only in patients with well-controlled arterial hypertension and diabetes, as well as exclusion of vascular malformations and cerebral amyloid angiopathy. The composite primary endpoint comprised of recurrent CNS hemorrhage, ischemic stroke, and mortality; secondary endpoints were separate aforementioned outcomes.

Results

Of the 54 patients included, 18 died within a month of CNS hemorrhage. The average observational time was 590 days. DOACs were reinitiated in 13/36 patients (36%); of these patients, three died: none due to ischemic stroke or recurrent CNS bleeding. In 23 patients, anticoagulation was not reinitiated; of these patients, 10 died: three from recurrent CNS hemorrhage, one due to ischemic stroke, and six from causes unrelated to stroke.

Conclusions

In carefully selected patients, re-initiation of DOAC therapy did not increase the rate of both endpoints. Recommendations for DOAC re-initiation, which include hypertension and diabetes control, as well as treated vascular malformations, and excluded cerebral amyloid angiopathy, appear to be valid in clinical practice.

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Acknowledgments

The authors would like to express thanks to all the co-workers at the Department of Vascular Neurology, UMC Ljubljana, who took care of the patients.

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Authors and Affiliations

  1. Department of Vascular Neurology, University Medical Centre Ljubljana, Zaloška 2, 100, Ljubljana, Slovenia

    Senta Frol & Janja Pretnar Oblak

  2. Neurology Department, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia

    Senta Frol & Janja Pretnar Oblak

  3. Department for Vascular Disorders, University Medical Centre Ljubljana, Ljubljana, Slovenia

    Mišo Šabovič

  4. Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia

    Mišo Šabovič

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  1. Senta Frol
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  2. Mišo Šabovič
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  3. Janja Pretnar Oblak
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Contributions

SF and JPO were involved in data collection, drafting of the manuscript, study design, and data interpretation. MS contributed to drafting of the manuscript, study design, and data interpretation. All authors give their final approval for this version to be published.

Corresponding author

Correspondence to Senta Frol.

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Conflict of interest

In the past 2 years, S.F, J.P.O. and M.S. have received honoraria for oral presentations from Bayer, Boehringer Ingelheim and Pfizer Inc.

Ethical approval

This study was approved by the Republic of Slovenia National Medical Ethics Committee.

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Frol, S., Šabovič, M. & Oblak, J.P. Re-initiation of anticoagulation after central nervous system hemorrhage during treatment with direct oral anticoagulants: a single hospital cohort study. Neurol Sci 42, 2005–2012 (2021). https://doi.org/10.1007/s10072-020-04776-w

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  • DOI: https://doi.org/10.1007/s10072-020-04776-w

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