# Management and Outcomes of Intracranial Hemorrhage in Atrial Fibrillation Patients: Highlighting Practices in Saudi Arabia

## TL;DR

This study examines how intracranial hemorrhage is managed in Saudi Arabia among patients with atrial fibrillation, highlighting high mortality and the need for standardized guidelines.

## Contribution

The study provides insights into ICH management practices and outcomes specific to Saudi Arabia's atrial fibrillation population.

## Key findings

- 47.2% of patients died during hospitalization, indicating high mortality.
- Higher BMI, diabetes, elevated INR, and lower GCS were associated with increased in-hospital mortality.
- Only 5.5% of discharged patients developed a recurrent ischemic stroke, suggesting low stroke recurrence.

## Abstract

Objectives: Atrial fibrillation (Afib) requires anticoagulation to prevent strokes; however, it concurrently increases the risk of bleeding, including intracranial hemorrhage (ICH). Balancing thromboembolism prevention with bleeding risk is challenging, and guideline variations add uncertainty. Evaluating patient factors and ICH management is key to optimizing treatment and outcomes.

Methods: This is a retrospective cohort study conducted in King Abdulaziz Medical City in Jeddah, Saudi Arabia. This design is particularly well-suited for studying rare events like ICH, as it enables the inclusion of a larger sample size over an extended time period without the need for a long follow-up. Patients were identified through medical records of those with Afib on anticoagulation who developed ICH, confirmed by brain CT. The primary endpoint was to evaluate the management, outcome, and prognosis of ICH in these patients. The secondary endpoint was to assess the association between clinicopathological features and in-hospital mortality.

Results: A total of 36 patients were included in this study. Patients who were ≥ 70 years old accounted for 52.7%, and males constituted 61.1% of the patients. Spontaneous ICH was seen in 72.2%, while the rest were traumatic in origin. Conservative management was done in 80.5%; 69.4% had their Afib medication ceased upon admission, and only 66.6% of those had their Afib medications resumed. The factors associated with mortality during hospital admission included higher BMI (30.2 (26.3-33.1) vs. 25.1 (22.1-29.2), P = 0.0255), diabetes (14 (82.3%) vs. 8 (42.1%), P = 0.0134), higher International Normalized Ratio (INR) (1.8 (1.2-2) vs. 1.2 (1.1-1.3), P = 0.0356), spontaneous ICH (15 (88.2%) vs. 11 (57.8%), P = 0.0425), and Glasgow Coma Scale (GCS) ≤ 8 (15 (88.2%) vs. 4 (21.0%), P = 0.0002). Regarding the outcome, 47.2% passed away during their hospital stay. Upon discharge, 78.9% had a GCS score of ≥ 14; apixaban was the most common medication prescribed (42.1%). The follow-up periods of the discharged patients had a median of 445 days; 33.3% passed away, while only 5.5% of them developed a recurrent ischemic stroke.

Conclusion: Our findings revealed that ICH in Afib patients is associated with high mortality and overall poor prognosis. There is a clear need for standardized management guidelines. Further studies are essential to establish evidence-based recommendations and reach reliable conclusions to improve patient outcomes.