@article{2997590,
    title = "Optimization of risk stratification for anticoagulation-associated intracerebral hemorrhage: net risk estimation",
    author = "Lioutas, V.-A. and Goyal, N. and Katsanos, A.H. and Krogias, C. and Zand, R. and Sharma, V.K. and Varelas, P. and Malhotra, K. and Paciaroni, M. and Karapanayiotides, T. and Sharaf, A. and Chang, J. and Kargiotis, O. and Pandhi, A. and Palaiodimou, L. and Schroeder, C. and Tsantes, A. and Boviatsis, E. and Mehta, C. and Serdari, A. and Vadikolias, K. and Mitsias, P.D. and Selim, M.H. and Alexandrov, A.V. and Tsivgoulis, G.",
    journal = "Egyptian Journal of Neurology, Psychiatry and Neurosurgery",
    year = "2020",
    volume = "267",
    number = "4",
    pages = "1053-1062",
    publisher = "Springer-Verlag",
    doi = "10.1007/s00415-019-09678-2",
    keywords = "anticoagulant agent;  antivitamin K;  creatinine;  hydroxymethylglutaryl coenzyme A reductase inhibitor;  anticoagulant agent, aged;  anticoagulation;  Article;  brain hemorrhage;  brain ischemia;  cardiovascular risk;  CHA2DS2-VASc score;  chronic kidney failure;  clinical assessment;  cohort analysis;  controlled study;  disease association;  female;  HAS BLED score;  high risk behavior;  human;  hypertension;  major clinical study;  male;  multicenter study;  prevalence;  priority journal;  process optimization;  prospective study;  risk assessment;  risk factor;  treatment indication;  brain hemorrhage;  brain ischemia;  severity of illness index;  very elderly, Aged;  Aged, 80 and over;  Anticoagulants;  Cerebral Hemorrhage;  Cohort Studies;  Female;  Humans;  Ischemic Stroke;  Male;  Risk Assessment;  Severity of Illness Index",
    abstract = "Background: Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification. Methods: We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA2DS2-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative, “Unfavorable”. Results: We enrolled 357 patients [59% men, median age 76 (68–82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66–80) vs 78 (73–84) years, p = 0.001], with lower CHA2DS2-VASc score [3(3–4) vs 5(4–6), p < 0.001]. Those with favorable indication had a significantly higher prevalence of most cardiovascular risk factors and were more likely to use a NOAC (35% vs 25%, p = 0.045). Both groups had similar prevalence of hypertension and chronic kidney disease. Conclusions: In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk. © 2019, Springer-Verlag GmbH Germany, part of Springer Nature."
}