The Practical Management of Intracerebral Hemorrhage Associated with Oral Anticoagulant Therapy

Abstract

Oral anticoagulant-associated intracerebral hemorrhage is increasing in incidence and is the most feared complication of therapy with vitamin K1 antagonists. Anticoagulant-associated intracerebral hemorrhage has a high risk of ongoing bleeding, death, or disability. The most important aspect of clinical management of anticoagulant-associated intracerebral hemorrhage is represented by urgent reversal of coagulopathy, decreasing as quickly as possible the international normalized ratio to values ≤1·4, preferably ≤1·2, together with life support and surgical therapy, when indicated. Protocols for anticoagulant-associated intracerebral hemorrhage emphasize the immediate discontinuation of anticoagulant medication and the immediate intravenous administration of vitamin K1 (mean dose: 10-20 mg), and the use of prothrombin complex concentrates (variable doses calculated estimate circulating functional prothrombin complex) or fresh-frozen plasma (15-30 ml/kg) or recombinant activated factor VII (15-120 μg/kg). Because of cost and availability, there is limited randomized evidence comparing different reversal strategies that support a specific treatment regimen. In this paper, we emphasize the growing importance of anticoagulant-associated intracerebral hemorrhage and describe options for acute coagulopathy reversal in this setting. Additionally, emphasis is placed on understanding current consensus-based guidelines for coagulopathy reversal and the challenges of determining best evidence for these treatments. On the basis of the available knowledge, inappropriate adherence to current consensus-based guidelines for coagulopathy reversal may expose the physician to medico-legal implications.

Warfarin‐related intracerebral haemorrhage: better outcomes when reversal includes prothrombin complex concentrates

“…1,5,7,11,12 There are no RCT data to guide us, although one is currently recruiting. 29 Reversal with PCC appears the most promising, with rapid reversal, and hints of improved outcomes.…”

“…5,12 All WRICH, even those with relatively small volume and better prognosis bleeds, should have urgent reversal of the coagulopathy to avoid clinical deterioration from HE. 7 There are haematology guidelines for the reversal of warfarin-related coagulopathy, 13 but a consistent approach is lacking in the stroke literature. 5 Treatments with vitamin K and other products (fresh frozen plasma (FFP), prothrombin complex concentrate (PCC) and factor VIIa) have not been subjected to a randomised controlled trial (RCT) in this patient group, and furthermore there are concerns regarding thrombotic complications with rapid reversal of anticoagulation 7,14 A previous local audit (for the period [1996][1997][1998][1999][2000][2001][2002][2003][2004][2005][2006] showed inadequate reversal of the warfarin-associated coagulopathy.…”

“…1,5 Estimates of WRICH frequency vary between 6% and 24% of all intracerebral haemorrhages (ICH). 3,[5][6][7] Higher international normalised ratios (INR) have a higher risk of WRICH, but most WRICH occur at an INR within the target therapeutic range. 3,4,7 The volume of ICH is a major predictor of outcomes.…”

“…3,[5][6][7] Higher international normalised ratios (INR) have a higher risk of WRICH, but most WRICH occur at an INR within the target therapeutic range. 3,4,7 The volume of ICH is a major predictor of outcomes. 8 Haematoma expansion (HE) can continue in the first 2-3 h after primary ICH but may be much longer in WRICH.…”

Neurosurgical treatment of cerebrovascular complications of heart surgeries and interventions

“…The treatment measures used to normalize haemocoagulation include vitamin K (very slow response time), fresh frozen plasma (fluid overload, slow response), and prothrombin complex concentrates with narrow therapeutic windows (potentially inducing thrombosis) (21). There is a risk of creating a prothrombotic state during acute anticoagulation reversal, but the risk of haematoma progression outweighs this risk (11).…”