Mitigating Hematoma Expansion: HCP Insights

Currently, much of the available data regarding hematoma expansion are limited to small observational studies that are often conducted at a single center. These studies also vary considerably in their methodology for the care of patients with life-threatening bleeds, including the use of reversal or replacement agents.

Based on these studies, best estimates are that hematoma expansion rates range anywhere from around 10-40% in DOAC-related ICH^6-9.

FXa inhibitor–related major bleeds can occur at several sites. These major bleeds can be bucketed into four categories: intracranial hemorrhages (ICH), bleeding at a critical site (intraocular, pericardial, intraspinal, intra-articular), bleeds resulting from major trauma (blunt or penetrating injury), and major bleeds with hemodynamic instability (gastrointestinal, retroperitoneal, genitourinary tract).^10-12

Non-valvular atrial fibrillation trials for apixaban (ARISTOTLE) and rivaroxaban (ROCKET-AF) reported major bleeding by site. In ARISTOTLE, the rates of intracranial hemorrhage and gastrointestinal bleeding in the apixaban group were 0.33% per year and 0.76% per year, respectively.² In ROCKET-AF, the rates of intracranial hemorrhage and gastrointestinal bleeding in the rivaroxaban group were 0.77% per year and 3.15% per year, respectively.³ Due to differences in trial design and patient populations, no direct comparisons between the agents can be made.

Currently, much of the available data regarding hematoma expansion are limited to small observational studies that are often conducted at a single center. These studies also vary considerably in their methodology for the care of patients with life-threatening bleeds, including the use of reversal or replacement agents.

In a single-center chart review of 9 intracerebral hemorrhage patients taking DOACs, 44% experienced hematoma expansion within 6 hours.⁹

This aligns with what is seen in clinical practice, according to Dr Adeoye, who states “In my experience, the peak of the expansion window occurs between onset of bleeding (from a patient’s perspective versus admission time) until about the 6-hour time point for patients on anticoagulants. After 6 hours, I often say that these anticoagulated patients have a prolonged “trickle” type of bleeding which may last up to 48 hours, as opposed to the large degree of expansion that occurs in the early phase of the bleeding”. In contrast, many non-anticoagulated patients aren’t “oozing” in this same fashion by 24 hours.