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Warfarin Reversal in Anticoagulant-Associated Intracerebral Hemorrhage

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Abstract

Anticoagulant-associated intracerebral hemorrhage (ICH) is a devastating disease, causing death in half of patients and permanent disability in the majority of survivors. The finding that patients often continue bleeding after hospital presentation offers the possibility that emergency warfarin reversal may improve outcomes. As no clinical trials have demonstrated the superiority of any one treatment strategy, various treatment options are available. Intravenous vitamin K is the definitive therapy; however, as monotherapy it can require many hours to take effect. Therefore, it is often considered an adjunct agent. Coagulation factors can be repleted with fresh frozen plasma (FFP), which is widely available and relatively low cost, but can require substantial time to deliver in real-world settings. A number of coagulation factor products collectively termed prothrombin complex concentrates (PCCs) are widely available that can rapidly provide many or all the vitamin K-dependent coagulation factors. Recombinant activated factor VII is used in many centers for this purpose, as it is thought to provide a procoagulant effect that may compensate for the lack of the other critical factors. Until clinical trials demonstrate the superiority of any one means of warfarin reversal, a number of expert guidelines from national organizations are available to help local providers guide therapy. At our institution, we have focused on improving the rapid and reliable delivery of a combination of intravenous vitamin K and FFP, with continued re-dosing until the desired INR lowering is achieved.

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Acknowledgments

We thank Dr. Walter (Sunny) Dzik for helpful discussion and commentary. Grant support: Funding from the Miles and Eleanor Shore 50th Anniversary Fellowship Award, the National Institute of Neurological Disorders and Stroke (NIH 1 K23 NS42695, R01 NS04217), and the Jerome Lyle Rappaport Charitable Foundation.

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  1. Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Joshua N. Goldstein

  2. Department of Neurology, Massachusetts General Hospital, Harvard Medical School, ACC 720, 55 Fruit Street, Boston, MA, 02114, USA

    Jonathan Rosand & Lee H. Schwamm

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Goldstein, J.N., Rosand, J. & Schwamm, L.H. Warfarin Reversal in Anticoagulant-Associated Intracerebral Hemorrhage. Neurocrit Care 9, 277–283 (2008). https://doi.org/10.1007/s12028-008-9049-z

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