LAUSR

Introduction: Prior clinical trials of oral anticoagulant (OAC) reversal have demonstrated improved outcomes in patients with OAC-related intracerebral hemorrhage (ICH). However, despite guidelines recommend avoiding the withdrawal of medical support within the first 2 days, about a quarter of OAC-related ICH patients do not receive an OAC reversal agent. We aimed to determine factors predictive of the administration of an OAC reversal agent in these patients. Methods: Prespecified analysis from the Anticoagulant-Related ICH (ARICH) registry, a multicenter, prospective, observational registry of adult patients with anticoagulant-related ICH <24 hours at 18 stroke centers in Spain. Direct-arriving patients under OAC treatment presented from March 2019 to March 2024 were included. Prior OAC treatment was collected, including those with an available specific reversal agent in our setting (vitamin K antagonists [VKA] and dabigatran [anti-FIIa]) and those without (rivaroxaban, apixaban, or edoxaban [anti-FXa]). The primary outcome was the administration of any OAC reversal agent. Results: We included 867 patients (baseline characteristics in Table 1): 460 (53.1%) on VKA, 28 (3.2%) on anti-FIIa, and 379 (43.7%) on anti-FXa. An OAC reversal agent was administered to 660 [76.1%] patients, at a median onset-to-treatment time of 300 (155–724) min. Patients not receiving a reversal agent were more frequently those without available specific reversal (86 [41.5%] vs. 402 [60.9%], P <0.001), with lower GCS score (11 [4–15] vs. 15 [13–15], P <0.001), and with a higher ICH volume (28.0 [6.3–69.4] vs. 11.1 [3.4–29.3] mL, P <0.001), but not with a lower INR in the VKA subgroup (2.5 [1.8–3.2] vs. 2.6 [2.1–3.0], P =0.167). These associations remained significant in multiple logistic regression analysis (Table 1, Fig. 1). A GCS score <10 (accuracy 0.78) and an ICH volume >33.6 mL (accuracy 0.71) were the thresholds that best predicted the non-receipt of a reversal agent. Conclusions: Among patients with acute OAC-related ICH, the unavailability of a specific reversal agent in our setting decreases the likelihood of receiving reversal treatment, highlighting the need to ensure the availability of specific agents. The observed thresholds of GCS and ICH volume for withholding treatment are more restrictive than those considered in OAC-reversal trials, underscoring the need to improve decision-making regarding the withdrawal of medical support in the acute phase of OAC-related ICH.