Wern Yew Ding, MBChB

Fernando SM, Qureshi D, Talarico R, Tanuseputro P, Dowlatshahi D, Sood MM, Smith EE, Hill MD, McCredie VA, Scales DC, et al. Intracerebral Hemorrhage Incidence, Mortality, and Association With Oral Anticoagulation Use: A Population Study. Stroke. 2021.

Intracranial hemorrhage (ICH) is the second most common form of stroke and is associated with significant morbidity and mortality. A small proportion of this is related to the use of oral anticoagulation. Given the increased adoption of specialized stroke units, the outcome of these patients may have improved. In this study of adult patients with a diagnosis of ICH in Ontario between April 2009 and March 2019, Fernando and colleagues sought to investigate the incidence, trends, and short- and long-term outcomes following ICH at a population level. For this purpose, the authors utilized the health administrative database from the entire population of Ontario, Canada. Patients with spontaneous, non-traumatic ICH were identified using ICD-10 codes that were specifically chosen to avoid misclassification bias such as those with hemorrhagic transformation from ischemic stroke.

The overall incidence of ICH was 18.6 per 100,000 person-years, increasing substantially with age: 2.3 per 100,000 person-years in those aged 18 to 44 years, and 147.6 per 100,000 person years in those aged equal or over 85 years. While the incidence of ICH has remained constant over the past decade, both in-hospital and 1-year mortality rates have declined. The in-hospital, 30-day and 1-year mortality for these patients were 32.4%, 34.7% and 45.4%, respectively. Predictors of excess mortality were advanced age, increased comorbidity burden, pre-existing long-term care residency, rural residency, lower income and use of oral anticoagulation (only evaluated in those aged over 65 years). The median length of stay was 9 days. Only 14.5% of patients who were admitted with ICH were discharged home independently.

The findings from this study highlight the severity of ICH both in terms of morbidity and mortality. Despite clinical improvements in the management of these patients, few regain independence after their event. It is also important to note that the incidence of ICH has remained consistent despite the introduction of non-vitamin K oral anticoagulants, which have been shown to reduce the risk of ICH over warfarin. This is likely due to the fact that only a minority of spontaneous ICH is related to the use of oral anticoagulation, as demonstrated by the authors. Overall, this study presents useful data on the contemporary burden of ICH.