Abdel Salam Kaleel, MD, MSc

Hagii J, Tomita H, Metoki N, Saito S, Shiroto H, Hitomi H, et al. Characteristics of Intracerebral Hemorrhage During Rivaroxaban Treatment: Comparison With Those During Warfarin. Stroke. 2014

This study compared the clinical characteristics, neuroradiologic findings, and functional outcomes of patients taking rivaroxaban and patients taking warfarin for nonvalvular atrial fibrillation who subsequently developed intracerebral hemorrhages. In particular, it sought to determine which group had more favorable characteristics after ICH. This study was conducted between April 2011 and October 2013 in the Hirosaki Stroke and Rehabilitation Center and included 585 ICH patients, 5 of whom had ICH while taking rivaroxaban, 56 of whom had ICH while taking warfarin, and 524 of whom had ICH on no anticoagulant therapy. ICH was diagnosed by immediate computed tomography (CT) with a follow up scan at day 2
after admission. The hematoma volume, expansion of hematoma, and extent of cerebral microbleeds were determined in surviving patients; Vitamin K was given for reversal of anticoagulation in patients on warfarin, but no reversal was given for patients previously on rivaroxaban. Scales and scores, namely CHADS2, HAS-BLED, and modified Rankin Scales, were determined on each patient. The differences were then computed by Mann-Whitney U test or Fisher’s exact test. 

Interestingly, patients on rivaroxaban had a smaller hematoma volume while none of them had expansion of hematoma or underwent surgical treatment. Those patients who had been taking warfarin on admission experienced expansion of hematoma in 21% and required surgical treatment in 11%. These findings occurred in the setting of rivaroxaban-treated patients having more cerebral microbleeds than the warfarin-treated group. When comparing the patients with mRS of 0 and 1 before admission, none of the patients in the rivaroxaban group had mRS >4 at discharge, but half of the patients taking warfarin did. Additionally, ten of the warfarin-treated patients died whereas none of the rivaroxaban-treated patients did. While the study did have several limitations, including single-center retrospective analysis and small number of study patients, it did provide valuable comparisons and some insight in characteristics of patients who suffered from ICH while taking warfarin or rivaroxaban.