ArticleBMJ neurology open2026
Anticoagulation associated intracerebral haemorrhage trends, treatment and outcomes in a metropolitan cohort: analysed by availability of specific versus non-specific reversal agents.
Article in BMJ neurology open, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran) and warfarin treatment are associated with an increased risk of intracerebral haemorrhage (ICH). Specific reversal exists for warfarin (vitamin K/prothrombin complex concentrate (PCC)) and dabigatran (idarucizumab). Data on protocol-guided non-specific 3-factor PCC for factor Xa inhibitor reversal are lacking. Aims: Our retrospective cohort study aimed to assess anticoagulation-related ICH secular trends. We also aimed to compare administration of reversal and antihypertensive treatments, where specific reversal agents were (dabigatran and warfarin) and were not (apixaban and rivaroxaban) available. Methods: We included patients with anticoagulation-related non-traumatic ICH of <24 hours duration from South Australian Stroke units (January 2017-December 2023). Outcomes analysed included 30-day mortality and discharge modified Rankin Scale. Secondary outcomes included time to administration of reversal agent, intravenous antihypertensives and time to systolic blood pressure (BP) lowering <140 mm Hg. Results: Of 310 included patients (median age 83 (76, 87)), 208 (67%) were in the factor Xa inhibitor group and 102 (33%) in the warfarin/dabigatran group. The proportion of factor Xa inhibitor-associated ICH increased from 3.7% in 2017 to 19.8% in 2023 (p<0.0001). The warfarin/dabigatran group was more likely to receive reversal (57% warfarin/dabigatran vs factor Xa inhibitor 39%, p=0.005). Where administered, time from hospital arrival to reversal did not differ between groups (132 min (94, 231) warfarin/dabigatran vs factor Xa inhibitor 126 (60, 225); p=0.3), nor did time to first dose of intravenous antihypertensives, time to BP <140 mm Hg and 30-day mortality. Conclusion: Factor Xa inhibitor-related ICH increased proportionally over the study period. These patients were less likely to receive reversal treatment than warfarin/dabigatran-related ICH. There was no difference between time to administration of PCC and time to antihypertensive metrics. The high mortality in our study underscores the need for effective optimised and timely treatments.
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