Characteristics of Intracerebral Hemorrhage During Rivaroxaban Treatment: Comparison With Those During Warfarin

Study Questions:

What are the characteristics of intracranial hemorrhage (ICH) events in patients treated with rivaroxaban versus warfarin?


Between 2011 and 2013, 585 consecutive patients admitted to a single stroke center with ICH were examined. Patients were categorized based on exposure to an anticoagulant and the type of anticoagulant (rivaroxaban vs. warfarin) at the time of ICH hospitalization. Clinical characteristics, neuroradiological findings, and functional outcomes were compared in the two anticoagulated groups.


Of the 585 patients admitted with ICH, five patients (1%) were treated with rivaroxaban and 56 (10%) were treated with warfarin at the time of their ICH event. Patients were at equivalently high risk for major bleeding, as estimated by the HAS-BLED score (median score of 3 for rivaroxaban-exposed and 4 for warfarin-exposed patients, p = 0.11). Hematoma expansion did not occur in the rivaroxaban group, but did occur in 10 (21%) warfarin-exposed patients. Hematoma volume was smaller in the rivaroxaban group versus the warfarin group (4 vs. 11 ml, p = 0.03). Rivaroxaban-exposed patients had lower Rankin Scale scores at discharge compared to warfarin-exposed patients, along with a smaller difference in Rankin Scale score between admission and discharge (1 vs. 3, p = 0.047). In-hospital death did not occur in the rivaroxaban-exposed group, but did occur in 10 (18%) of the warfarin-exposed group.


The authors concluded that rivaroxaban-associated ICH occurs in higher bleeding-risk patients but with smaller hematoma volume, less frequent hematoma expansion, and better functional status compared to the warfarin-associated ICH group.


This single-center case series highlights some important differences in patients suffering from ICH while treated with anticoagulant agents. Despite these patients being at nearly equivalent bleeding (as estimated by the HAS-BLED score), there were more favorable outcomes in the rivaroxaban-exposed group compared to the warfarin-exposed group. While caution should be taken at drawing strong conclusions from single-center experiences with small numbers of events, this report offers some encouraging news for patients and practitioners weary of ICH risk and clinical outcomes when taking a ‘nonreversible’ anticoagulation, such as rivaroxaban. Additional clinical experience will help to further inform this important piece of the decision-making process for anticoagulation therapy.

Clinical Topics: Anticoagulation Management

Keywords: International Normalized Ratio, Stroke, Warfarin, Hematoma

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