Clinical and Radiological Evaluation of Warfarin-Associated Intracerebral Hemorrhage (ICH) in Patients With Mechanical Prosthetic Heart Valves: A Retrospective Observational Study

Introduction: Intracerebral hemorrhage (ICH) is a serious complication of oral warfarin in patients with mechanical heart valves, leading to high mortality and disability. This study aimed to evaluate the clinical and radiological features and the variables associated with patient outcomes in such cases, particularly in resource-limited settings. Methods: This retrospective observational study included 125 patients on warfarin with mechanical heart valves who developed spontaneous ICH and presented within 24 hours of symptom onset. Hematoma volume was calculated using the ABC/2 method. Outcomes were assessed at 90 days across the entire cohort using mortality data and the modified Rankin Scale (mRS), with mRS ≥3 indicating poor functional recovery. Results: Among the 125 patients, 42 (33.6%) died within 90 days, and 38 (30.4%) experienced poor functional recovery (mRS ≥3). Unadjusted analyses identified several shared clinical and radiological variables significantly associated with both mortality and poor functional recovery, respectively: advanced age >60 years (p=0.024; p=0.005), hypertension (p=0.007; p=0.045), smoking (p=0.002; p=0.040), atrial fibrillation (p=0.012; p=0.011), anemia (p=0.024; p<0.001), hematoma volume >30 cc (p=0.033; p=0.004), midline shift (p<0.001; p=0.010), and higher composite ICH scores (p=0.035; p=0.014). Furthermore, intraventricular extension (p=0.005) and severe admission blood pressure >230/140 mmHg (p=0.019) were specifically linked to increased mortality. A low admission Glasgow Coma Scale (GCS) score <8 (p<0.001) was associated with poor functional recovery among survivors. While an association was observed between neurosurgical intervention and improved functional outcomes in unadjusted analyses, this finding should be interpreted with caution, given the potential selection bias inherent in the retrospective design. Conclusion: Warfarin-associated ICH in patients with mechanical heart valves remains a devastating complication characterized by high rates of mortality and long-term functional disability. This study identified several clinical and radiological variables associated with adverse outcomes, including advanced age, large hematoma volume, midline shift, intraventricular extension, low admission GCS, and concurrent comorbidities such as anemia and severe hypertension. Optimizing outcomes in this vulnerable population requires early risk stratification using comprehensive clinical grading systems such as the ICH score, rapid neuroimaging, rigorous blood pressure control, international normalized ratio (INR) reversal, and individualized, selective neurosurgical interventions.