Background: In intracerebral hemorrhage (ICH), hematoma expansion (HE) is a major predictor of mortality and morbidity. A rapid approach, including oral anticoagulant (OAC) reversal and blood pressure (BP) reduction, both <60 min from arrival, improves outcomes. We aimed to evaluate current time metrics in the management of anticoagulant-associated intracerebral hemorrhage (AAICH) and their impact on HE in a high-income setting. Methods: Consecutive AAICH patients presenting to a high-volume stroke center (2017-2023) were retrospectively identified. Clinical and imaging data were merged, with baseline and follow-up hematoma volumes quantified using 3D Slicer segmentation software. Results: Of 75 AAICH patients, 62 received antihypertensives and 52 OAC reversal, with median(IQR) times to BP control: 87.5 (61-207) minutes and median time to OAC reversal: 67.5 (49-96) minutes. Only 14 (23%) and 23 (44%) achieved treatment targets <60 minutes, respectively, and 7 (9%) patients achieving both targets. HE occurred in 27 of 48 patients with follow-up imaging. Median time to target BP was significantly longer in those with HE (186.5 (87-317) min) compared to those without HE (70 (56-104) min), p=0.01. Conclusions: Current management of AAICH remains heterogeneous, with considerable treatment delays regarding BP control and OAC reversal. These findings support the implementation of standardized protocols to optimize AAICH treatment.

Background: We evaluated (1) the predictive accuracy and (2) multi-observer reliability of non-contrast CT markers of hematoma expansion (HE). Methods: In 124 patients with spontaneous intracerebral hemorrhage, two investigators documented the presence of six density (Barras density, hypodensity, black hole, swirl, blend, fluid level) and three shape (Barras shape, island, satellite) expansion markers, with discrepancies resolved by a third rater. We defined HE as any one of (1) >6 mL absolute or >33% relative growth of the intraparenchymal hematoma or (2) an absolute growth of >1 mL or new development of intraventricular hematoma. A subsample of 60 patients was used for the inter-observer reliability study in 13 raters. Seven raters participated in the intra-rater study. Results: The sensitivity of markers for HE varied between 4% (fluid level) and 78% (satellite), while specificity ranged from 37% (swirl) to 97% (black hole). Almost perfect inter-rater agreement was observed for the swirl (0.89) and fluid level (0.83) markers, while hypodensity (0.65) showed substantial agreement. Only the blend and fluid level markers achieved substantial intra-rater agreement (> 0.6) in all raters. Conclusions: Non-contrast CT markers of HE showed lower reliability and predictive accuracy than previously reported. Future studies should address means to improve NCCT-based HE prediction.