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August 2018; 8 (4) Research

Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin

Heidi Lehtola, Antti Palomäki, Pirjo Mustonen, Päivi Hartikainen, Tuomas Kiviniemi, Henri Sallinen, Ilpo Nuotio, Antti Ylitalo, K.E. Juhani Airaksinen, Juha Hartikainen
First published July 12, 2018, DOI: https://doi.org/10.1212/CPJ.0000000000000491
Heidi Lehtola
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Antti Palomäki
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Pirjo Mustonen
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Päivi Hartikainen
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Tuomas Kiviniemi
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Henri Sallinen
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Ilpo Nuotio
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Antti Ylitalo
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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K.E. Juhani Airaksinen
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Juha Hartikainen
Department of Medicine (HL, PM), Keski-Suomi Central Hospital, Jyvaskyla; Department of Cardiology (HL), Oulu University Hospital; Heart Center (AP, TK, HS, AY, KEJA) and Department of Acute Internal Medicine (IN), Turku University Hospital; NeuroCenter (PH), Kuopio University Hospital; University of Turku (IN, KEJA); Satakunta Central Hospital (AY), Pori; and Heart Center (JH), Kuopio University Hospital and University of Eastern Finland.
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Citation
Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin
Heidi Lehtola, Antti Palomäki, Pirjo Mustonen, Päivi Hartikainen, Tuomas Kiviniemi, Henri Sallinen, Ilpo Nuotio, Antti Ylitalo, K.E. Juhani Airaksinen, Juha Hartikainen
Neurol Clin Pract Aug 2018, 8 (4) 311-317; DOI: 10.1212/CPJ.0000000000000491

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Abstract

Background Intracranial hemorrhage is the most devastating complication in patients with atrial fibrillation (AF) receiving oral anticoagulation (OAC). It can be either spontaneous or caused by head trauma. We sought to address the prevalence, clinical characteristics, and prognosis of traumatic and spontaneous intracranial hemorrhages in AF patients on OAC.

Methods Multicenter FibStroke registry of 5,629 patients identified 592 intracranial hemorrhages during warfarin treatment between 2003 and 2012.

Results A large proportion (40%) of intracranial hemorrhages were traumatic. Of these, 64% were subdural hemorrhages (SDHs) and 20% intracerebral hemorrhages (ICHs). With respect to the spontaneous hemorrhages, 25% were SDHs and 67% ICHs. Patients with traumatic hemorrhage were older (81 vs 78 years, p = 0.01) and more often had congestive heart failure (30% vs 16%, p < 0.01) and anemia (7% vs 3%, p = 0.03) compared to patients with spontaneous hemorrhage. Admission international normalized ratio (INR) values (2.7 vs 2.7, p = 0.79), as well as CHA2DS2-VASc (median 4 vs 4, p = 0.08) and HAS-BLED (median 2 vs 2, p = 0.05) scores, were similar between the groups. The 30-day mortality after traumatic hemorrhage was significantly lower than after spontaneous hemorrhage (25% vs 36%, p < 0.01).

Conclusions A significant proportion of intracranial hemorrhages in anticoagulated AF patients were traumatic. Traumatic hemorrhages were predominantly SDHs and less often fatal when compared to spontaneous hemorrhages, which were mainly ICHs. Admission INR values as well as CHA2DS2-VASc and HAS-BLED scores were similar in patients with spontaneous and traumatic intracranial hemorrhage.

Clinicaltrials.gov identifier NCT02146040.

Footnotes

  • ↵* These authors contributed equally to this work.

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Received February 6, 2018.
  • Accepted April 16, 2018.
  • © 2018 American Academy of Neurology
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The Nerve!: Rapid online correspondence

  • Author Response: Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin
    • Heidi Lehtola, Department of Cardiology, Oulu University Hospital, Oulu, Finland
    • Antti Palomäki, Department of Internal Medicine, Turku University Hospital, Turku, Finland
    • Pirjo Mustonen, Department of Internal Medicine, Keski-Suomi Centran Hospital, Jyväskylä, Finland
    • Päivi Hartikainen, Department of Neurology, Kuopio University Hospital, Kuopio, Finland
    • Juhani Airaksinen, Heart Center, Kuopio University Hospital, Kuopio, Finland
    • Juha Hartikainen, Heart Center, Kuopio University Hospital, Kuopio, Finland
    Submitted December 09, 2018
  • Reader Response: Traumatic and spontaneous intracranial hemorrhage in atrial fibrillation patients on warfarin
    • George K Vilanilam, Clinical Neurology Fellow, Mayo Clinic
    • Neethu Gopal, Research Trainee, Mayo Clinic
    • Anjali Agarwal, Research Trainee, Mayo Clinic
    • Mohammed K. Badi, Research Trainee, Mayo Clinic
    Submitted August 18, 2018
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