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Alexander Y. Zubkov, MD, PhD; Jayawant N. Mandrekar, PhD; Daniel O. Claassen, MD; Edward M. Manno, MD; Eelco F. M. Wijdicks, MD; Alejandro A. Rabinstein, MD

Arch Neurol. 2008;65(10):1320-1325.

Background  Intracerebral hemorrhage (ICH) associated with warfarin sodium therapy is becoming more common as the use of this medication increases in the aging population.

Objective  To delineate factors associated with early mortality, determine variables responsible for poor functional outcome, and evaluate possible reasons for expansion of hemorrhage and associated parenchymal edema.

Design  Retrospective study of clinical and radiologic information for 88 patients with warfarin-associated ICH.

Setting  A single hospital.

Patients  Eighty-eight consecutive patients with warfarin-associated ICH.

Methods  Patients were included if the international normalized ratio (INR) at presentation with ICH was 1.5 or greater. Computed tomographic scans were reviewed for volumetric analysis of hematoma and perihematomal edema volume. Outcome variables included 7-day mortality, hematoma enlargement, and functional outcome based on the modified Rankin Scale score.

Results  Seven-day mortality (39.8%) was associated with a lower Glasgow Coma Scale sum score and larger ICH volume at presentation. Univariate analysis revealed that a lower Glasgow Coma Score sum score, larger initial ICH volume, higher initial and 48-hour maximum glucose concentrations, and higher percentage of ICH expansion were significantly associated with poor functional outcome at hospital discharge. At multivariate analysis, only Glasgow Coma Score and ICH volume remained significantly associated with functional outcome measured at hospital discharge and at the last follow-up visit. Conversely, INR at presentation, time to INR correction, initial blood pressure, and enlargement of edema were not associated with functional outcome either at hospital discharge or at the last follow-up. Neither serum glucose concentration at admission nor highest level during the first 48 hours had any correlation with ICH or parenchymal edema enlargement. In addition, neither initial INR nor time to INR correction correlated with expansion of ICH or parenchymal edema.

Conclusions  Lower level of consciousness at presentation and larger initial ICH volume predict poor prognosis in patients with warfarin-associated ICH. In our study population, INR at presentation was not associated with functional outcome.

Author Affiliations: Departments of Neurology (Drs Zubkov, Claassen, Manno, Wijdicks, and Rabinstein) and Biostatistics (Dr Mandrekar), Mayo Clinic, Rochester, Minnesota.

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