Anticoagulation associated intracerebral haemorrhage trends, treatment and outcomes in a metropolitan cohort: analysed by availability of specific versus non-specific reversal agents
Research article published in BMJ neurology open (2026)
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.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran) and warfarin treatment are associated with an increased risk of intracerebral haemorrhage (ICH).
Why This Matters for Hirudotherapy
This retrospective cohort study assessed anticoagulation-related intracerebral hemorrhage trends and treatment patterns in 310 patients from South Australian stroke units (2017–2023), comparing outcomes where specific reversal agents were available (warfarin/dabigatran) versus unavailable (factor Xa inhibitors apixaban/rivaroxaban). The proportion of factor Xa inhibitor-associated ICH increased significantly over the study period, and these patients were less likely to receive reversal treatment, though time to reversal, antihypertensive metrics, and 30-day mortality did not differ significantly between groups. For ASH, this study's relevance is indirect—it concerns anticoagulant-associated bleeding management and reversal strategies, a clinical area conceptually related to anticoagulant action but with no involvement of leeches, hirudin, or the leech secretome.
Citation
Anticoagulation associated intracerebral haemorrhage trends, treatment and outcomes in a metropolitan cohort: analysed by availability of specific versus non-specific reversal agents
El-Masri S et al. · BMJ neurology open, 2026
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