Warfarin associated intracerebral hemorrhage in Hong Kong Chinese

Objectives: Warfarin-associated intracerebral hemorrhage (WICH) is a serious neurological condition associated with significant mortality and morbidity. We aimed to study the clinical features and factors that predict clinical outcome of Chinese patients with WICH.

Methods: Medical records of patients with spontaneous intracerebral hemorrhage (ICH) admitted to our hospital between July 2001 and June 2010 were reviewed and those with WICH were studied in detail retrospectively.

Results: Fifty-one patients with WICH were studied. The mean age was 74.3 ± 10.5 years and 52.9% of the patients were female. The mean international normalized ratio (INR) on presentation was 2.9 ± 1.0. The median ICH volume was 23·3 (10·4-59·3) ml. The mortality rate at 3-6 months for WICH was 62·0%. Multivariate logistic analysis revealed that an initial ICH volume of > 20 ml (OR 34·4, P = 0·037) and presence of intraventricular hemorrhage (OR 22.9, P = 0·046) were independently associated with poor outcome. Supratherapeutic INR (INR > 3.0) on admission (P = 0.724) and complete correction of INR within 24 hours after admission (P = 0·486) were not independent predictors of poor outcome. The median ICH volumes did not differ between INR groups (18·2 (9·4-61·1) ml for INR ≤ 3 vs 27.3 (13.7-58.5) ml for INR > 3, P = 0·718). Neurological deterioration (ND) was documented in 19 (63·3%) of the 30 patients included in a smaller sub-cohort, and was associated with poor neurological outcome (OR 20·7, P = 0·027). Warfarin was resumed in 7 of the 20 survivors. There were two episodes of recurrent WICH and one episode of ischemic stroke during a mean follow-up duration of 5·4 years. In survivors who were not resumed on warfarin, there were two episodes of recurrent ICH and 12 episodes of ischemic vascular events (nine ischemic strokes) during a mean follow-up duration of 2·6 years.

Conclusion: Warfarin-associated intracerebral hemorrhage is a very serious complication of warfarin therapy with high mortality and morbidity. Initial ICH volume, presence of intraventricular hemorrhage, and ND are independent predictors of clinical outcome.