Epidemiology and outcomes of intracerebral hemorrhage associated with oral anticoagulation over 10 years in a population-based stroke registry

Background: Recent years have seen a change in the use of anticoagulants in the general population due to both the availability of direct oral anticoagulants (DOACs) as an alternative to vitamin K antagonists (VKAs), and the increased detection of atrial fibrillation. It is important to have updated epidemiological data to understand how this change is impacting on the occurrence and outcome of intracerebral hemorrhage (ICH). Patients and methods: Our prospective population-based registry included patients with first-ever ICH occurring from January 2011 to December 2020. Oral anticoagulants (OAC)- related ICH was defined as an ICH occurring within 48 hours from the intake of DOAC or VKAs, regardless of the measured International Normalized Ratio on hospital admission. Results: We included 748 first-ever ICH, of whom 108 (14.4%) were OAC-related. Specifically, 75 (69.4%) ICHs occurred on VKA and 33 (30.6%) on DOAC. The incidence of OAC-ICH was stable over time (p=0.226). Among OAC-ICHs, we observed an increase in the overall incidence of DOAC-ICH (P for trend <0.001) which exceeded that of VKA-ICH in 2020 (IRR 4.71, 95% CI 1.22-33.54; p=0.022). Patients with OAC-ICH showed higher 30-day case-fatality rates than those with non-OAC-ICH (48.1% versus 34.1%; p=0.007). Conclusions: No changes over time between 2011 and 2020 were detected in the overall incidence of OAC-ICH, but there was a change in OAC-ICH from mostly VKA-related to mostly DOAC-related. Mortality in patients with OAC-ICH was higher than in patients with non-OAC-ICH.