Association of oral anticoagulants with risk of brain haemorrhage expansion compared to no-anticoagulation
Authors: Veltkamp Roland , Haas Kirsten , Rücker Viktoria , Malzahn Uwe , Heeger Adrian , Kinzler David , Müller Patrick , Rappard Pascal , Rizos Timolaos , Schiefer Johannes , Opherk Christian , Pfeilschifter Waltraud , Althaus Katharina , Schellinger Peter , Gaida Bernadette , Gabriel Maria Magdalena , Royl Georg , Nabavi Darius G. , Haeusler Karl Georg , Nolte Christian H. , Wolf Marc E. , Poli Sven , Sieber Marilen , Mosimann Pascal , Heuschmann Peter U. , Purrucker Jan C. ,   on behalf of the RASUNOA-prime investigators, Horstmann Solveig , Krauß Alexandra , Renninger Caroline , Ringleb Peter , Reich Arno , Kohler Eve , Boss Erendira , Schaefer Jan Hendrik , Pflug Marc , von Sarnowski Bettina , Große Gerrit Maximilian , Ernst Johanna , Weißenborn Karin , Schupper Ramona , Worthmann Hans , Riebau Susanne , Crome Olaf , Dimitrijeski Boris , Offermann Jens , Rangus Ida , Schmid Elisabeth , Poli Khouloud , Tünnerhoff Johannes , Michalski Dominik , Pelz Johann O. , Juenemann Martin , Müller Tobias BraunTobias J. , Wartenberg Katja , Binder Andreas , Meyne Johannes , Ikenberg Benno , Härtl Johanna , Ohms Michael , Edelbusch Sebasitan , Fatar Marc , Alonso Angelika , Nückel Martin , Erbguth Frank , Grau Alexandra , Selig Udo , Dziewas Rainer , Minnerup Jens , Barlinn Kristian , Haase Kathrin , Thomalla Götz , Deb-Chatterji Milani , Mäurer Mathias , Pfau Mathias , Michels Peter , Vukovic Zoran , Uphaus Timo , Gröschel Klaus , Gröschel Sonja , Hahn Marianne , Mühler Joannes , Dötter Klaus , Wagner-Heck Michaela , Wollenweber Frank Arne , Jander Sebastian , Lee John-Ih , Schäbitz Wolf-Rüdiger , Piehl Inken , Frattner Michael , Staykov Dimitre , Urbanek Christian , Schröder Sabine , Düllberg-Boden Sylke , Kermer Pawel , Kaste Matthias , Marquardt Lars , Kazarians Haiko , Kleinschnitz Christoph , Kraft Peter , Hoffmann Frank , Kraft Andrea , Faiss Jürgen Hartmut , Reimann Gernot , Schwarz Michael , Steiner Thorsten , Günther Albrecht , Lamadé Uta Meyding , Lorenz Matthias W. 
Published: February 2025

Abstract

Background
The impact of direct oral anticoagulants (DOAC) on haematoma size after intracerebral haemorrhage (ICH) compared to no-anticoagulation is controversial and prospective data are lacking.

Methods
The investigator-initiated, multicentre, prospective RASUNOA-prime study enrolled patients with non-traumatic ICH and atrial fibrillation while on a DOAC, vitamin K antagonist (VKA) or no anticoagulation (non-OAC). Neuroimaging was reviewed centrally blinded to group allocation. Primary endpoint was haematoma expansion (≥ 6.5 ml or ≥ 33%, any new intraventricular blood or an increase in modified Graeb score by ≥ 2 points) between baseline and follow-up scan within 72 h after symptom onset.

Results
Of 1,440 patients screened, 951 patients with ICH symptom onset less than 24 h before admission were enrolled. Baseline scans were performed at a median of 2 h (IQR 1–6) after symptom onset. Neurological deficit and median baseline haematoma volumes (11 ml; IQR 4–39) did not differ among 577 DOAC, 251 VKA and 123 non-OAC patients. Haematoma expansion was observed in DOAC patients in 142/356 (39.9, 95%-CI 34.8–45.0%), VKA in 47/155 (30.3, 95-CI 23.1%–37.6%), versus non-OAC in 22/74 (29.7, 19.3–40.1%). Unspecific reversal agents in DOAC-ICH (212/356, 59.6%) did not affect the haematoma expansion rate compared to no-antagonization.

Conclusion
Baseline haematoma volume and risk of haematoma expansion did not differ statistically significantly in patients with and without DOAC.