Optimization of risk stratification for anticoagulation-associated intracerebral hemorrhage: net risk estimation

Vasileios Arsenios Lioutas, Nitin Goyal, Aristeidis H. Katsanos, Christos Krogias, Ramin Zand, Vijay K. Sharma, Panayiotis Varelas, Konark Malhotra, Maurizio Paciaroni, Theodore Karapanayiotides, Aboubakar Sharaf, Jason Chang, Odysseas Kargiotis, Abhi Pandhi, Lina Palaiodimou, Christoph Schroeder, Argyrios Tsantes, Efstathios Boviatsis, Chandan Mehta, Aspasia SerdariKonstantinos Vadikolias, Panayiotis D. Mitsias, Magdy H. Selim, Andrei V. Alexandrov, Georgios Tsivgoulis

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Background: Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification. Methods: We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA2DS2-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative, “Unfavorable”. Results: We enrolled 357 patients [59% men, median age 76 (68–82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66–80) vs 78 (73–84) years, p = 0.001], with lower CHA2DS2-VASc score [3(3–4) vs 5(4–6), p < 0.001]. Those with favorable indication had a significantly higher prevalence of most cardiovascular risk factors and were more likely to use a NOAC (35% vs 25%, p = 0.045). Both groups had similar prevalence of hypertension and chronic kidney disease. Conclusions: In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk.

Original languageEnglish (US)
Pages (from-to)1053-1062
Number of pages10
JournalJournal of Neurology
Issue number4
StatePublished - Apr 1 2020

All Science Journal Classification (ASJC) codes

  • Neurology
  • Clinical Neurology


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