Abstract DP49: Time Metrics in Acute Management of Anticoagulant-Associated Acute Intracerebral Hemorrhage: The Need for Speed

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Introduction: Intracerebral hemorrhage (ICH) is associated with poor outcomes in part due to a lack of perceived sense of urgency. In low to middle-income countries, a rapid approach including oral anticoagulation (OAC) reversal and intensive blood pressure (BP) reduction <60 minutes improves outcomes and reduces hematoma expansion (HE). We aimed to assess and quantify current time metrics in anticoagulant-associated ICH (AAICH) management and the relationship with HE and in-hospital mortality in a high-income academic setting. Methods: Consecutive AAICH patients admitted to a Canadian high-volume comprehensive stroke center from 2017-2023 were examined. Clinical data were merged with ICH imaging at baseline&follow-up CT. Imaging analyses were performed using 3D Slicer segmentation software. HE was defined as per revised criteria (≥33% relative or ≥6 mL absolute increase in ICH volume, or new presence or ≥1mL increase in intraventricular hemorrhage). Results: Among 75 patients, mean±SD age was 79.8±9.1 years, 33% female, median(IQR) NIHSS 19(12-26), and median ICH volume 15.7(6-48) mL. Direct OAC were used in 68% (96% FXa inhibitors), and 28% warfarin. Mean admission systolic BP was 177.2±28.6 mmHg, with a 140 mmHg BP target in 94%. At 60 minutes from arrival, BP target was achieved in 24%, with a median time to BP target of 87.5(61-207) min. OAC reversal agents were administered in 52(69%) patients, 30(59%) on FXa inhibitors, 20(95%) on warfarin, and 2(100%) on dabigatran. The median time to OAC reversal was 68(49-96) min, with 42% treated <60 mins. Of the 46 (61%) patients who received both BP and OAC reversal treatments, 30 (43.5%) reached the <60 min. target for one treatment and 5 (7%) for both treatments. In 48 patients with follow-up CT and without neurosurgical intervention, HE occurred in 27(56%). The proportion of HE was larger in those who did not receive rapid BP reduction (21/27 vs. 6/27) and rapid OAC reversal (13/20 vs. 7/20) compared to those who did, respectively. In-hospital mortality (33/75, 44% overall) was similar in patients who did not achieve one (38%) or both (40%) treatment targets. Conclusions: Current management of AAICH remains suboptimal in a high-income academic setting, where only 7% of patients received both BP treatment and OAC reversal <60 minutes from hospital arrival. HE was more common among patients whose treatments were delayed. These findings expose the need for better management strategies to rapidly treat AAICH

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