Chronic Antithrombotic Therapy Alters ICH Presentation with No Effect on Minimally Invasive Endoscopic Evacuation

Introduction: Intracerebral hemorrhage(ICH) presents a significant clinical challenge with high mortality and disability rates. Despite emerging evidence from the ENRICH trial supporting the efficacy of minimally invasive surgery(MIS) for lobar ICH, the influence of antithrombotic therapies on MIS outcomes remains a concern. This study aims to elucidate the effects of chronic anticoagulant(AC) and antiplatelet(AP) therapies on the outcomes of patients with ICH undergoing MIS.

Methods: A prospectively collected registry of MIS for ICH patients was analyzed from a single institution between December 2015 and September 2022. For patients on AP or AC therapy, reversal was administered in alignment with the latest ICH guidelines. Patients were categorized into three groups: control (no antithrombotic medication history), AP only, and AC only. Variables showing statistical significance(p≤0.05) on univariate analyses were incorporated into multivariable linear regression models.

Results: Among 226 ICH patients treated with MIS, 93 (41%) were receiving antithrombotic medications: 64 (28%) were exclusively on AP therapy, and 21 (9%) were exclusively on AC therapy. Patients on AP therapy presented more frequently with lobar ICHs (56% vs 37%; p=0.022), and those on AC therapy showed increased rates of intraventricular hemorrhage co-presentation (62% vs 46%; p=0.011) compared to controls. Despite univariate analyses showing a higher postoperative hematoma volume (3.9 mL vs 2.9 mL; p=0.020) and lower evacuation percentage (88% vs 92%; p=0.019) for the AP group, and longer procedures for patients on AC therapy (2.3 hrs vs 1.7 hrs; p=0.042) compared to control, multivariable analyses indicated that AP and AC therapies had no significant impact on these technical outcomes. Longitudinally, AP and AC therapy were not associated with increased symptomatic postoperative bleeding, less frequent discharge to home or acute rehabilitation, lower 30-day mortality, or worse, 6-month Modified Rankin Scale scores.

Conclusion : Patients on chronic AP and AC therapies presented with characteristically unique ICH, but did not have worse technical or long-term clinical outcomes. These findings underscore the safety and efficacy of MIS for ICH in patients on antithrombotic therapy, informing neurosurgical care strategies for this subset.