Tsivgoulis G, et al. – Physicians designed this study to compare the neuroimaging profile and clinical outcomes among patients with intracerebral hemorrhage (ICH) related to use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF). At hospital admission, DOAC–related ICH was correlated with smaller baseline hematoma volume and lesser neurologic deficit compared to VKA–related ICH.

• Patients with NVAF with nontraumatic, anticoagulant-related ICH admitted at 13 tertiary stroke care centers over a 12-month period were consecutively evaluated.
• Furthermore, the physicians conducted a systematic review and meta-analysis of eligible observational studies reporting baseline characteristics and outcomes among patients with VKA- or DOAC-related ICH.

• A total of 161 patients with anticoagulation-related ICH were prospectively evaluated (mean age 75.6 ± 9.8 years, 57.8% men, median admission NIH Stroke Scale [NIHSSadm] score 13 points, interquartile range 6-21).
• Except for a higher prevalence of chronic kidney disease in VKA-related ICH, DOAC-related (n = 47) and VKA-related (n = 114) ICH did not differ in demographics, vascular risk factors, HAS-BLED and CHA2DS2-VASc scores, and antiplatelet pretreatment.
• In this study, patients with DOAC-related ICH had lower median NIHSSadm scores (8 [3-14] vs 15 [7-25] points, p = 0.003), median baseline hematoma volume (12.8 [4-40] vs 24.3 [11-58.8] cm³, p = 0.007), and median ICH score (1 [0-2] vs 2 [1-3] points, p = 0.049).
• In DOAC-related ICH, severe ICH (>2 points) was less prevalent (17.0% vs 36.8%, p = 0.013).
• DOAC-related ICH was independently correlated with lower baseline hematoma volume (p = 0.006), lower NIHSSadm scores (p = 0.022), and lower likelihood of severe ICH (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.13–0.87, p = 0.025) in multivariable analyses.
• DOAC-related ICH was correlated with lower baseline hematoma volumes on admission CT (standardized mean difference = -0.57, 95% CI -1.02 to -0.12, p = 0.010) and lower in-hospital mortality rates (OR = 0.44, 95% CI 0.21-0.91, p = 0.030) in meta-analysis of eligible studies.