Differences in Intracerebral Hemorrhage Between Warfarin and New Oral Anticoagulants

by Joseph Esherick, M.D., FAAFP, FHM

In prior randomized trials, the incidence of intracerebral hemorrhage (ICH) was significantly lower with the new oral anticoagulants (NOACs) than with warfarin (Blood 2014; 124:1968).  However, it remains unclear if clinical outcomes are similar when ICH does occur with different anticoagulants?  To address this question, U.K. researchers performed a retrospective study that compared 52 patients who suffered ICHs while taking warfarin with 11 patients who suffered ICHs while taking NOACs (6 on rivaroxaban, 3 on dabigatran, and 2 on apixaban). Patients with major head trauma or known structural reasons for ICH were excluded. Mean international normalized ratio (INR) was 2.5 in warfarin-treated patients.

The average ICH volume was 3.5-fold larger with warfarin than with NOACs (8.9 vs. 2.4 mL).  These larger ICHs in warfarin patients translated to worse functional outcomes at hospital discharge compared with NOAC patients.

Van Es, N et al.  Direct oral anticoagulants compared with vitamin K antagonists for acute venous thromboembolism: evidence from phase 3 trials.  Blood. 2014; 124: 1968


Wilson D et al. Volume and functional outcome of intracerebral hemorrhage according to oral anticoagulant type. Neurology. 2016 Jan 26; 86:360