Timing of INR reversal using fresh-frozen plasma in warfarin-associated intracerebral hemorrhage

  • Murtaza Akhter
  • Andrea Morotti
  • Abigail Sara Cohen
  • Yuchiao Chang
  • Alison M. Ayres
  • Kristin Schwab
  • Anand Viswanathan
  • Mahmut Edip Gurol
  • Christopher David Anderson
  • Steven Mark Greenberg
  • Jonathan Rosand
  • Joshua Norkin Goldstein
EM - ORIGINAL

Abstract

Rapid reversal of coagulopathy is recommended in warfarin-associated intracerebral hemorrhage (WAICH). However, rapid correction of the INR has not yet been proven to improve clinical outcomes, and the rate of correction with fresh-frozen plasma (FFP) can be variable. We sought to determine whether faster INR reversal with FFP is associated with decreased hematoma expansion and improved outcome. We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with WAICH presenting to an urban tertiary care hospital from 2000 to 2013. Patients with baseline INR > 1.4 treated with FFP and vitamin K were included. The primary outcomes are occurrence of hematoma expansion, discharge modified Rankin Scale (mRS), and 30-day mortality. The association between timing of INR reversal, ICH expansion, and outcome was investigated with logistic regression analysis. 120 subjects met inclusion criteria (mean age 76.9, 57.5% males). Median presenting INR was 2.8 (IQR 2.3–3.4). Hematoma expansion is not associated with slower INR reversal [median time to INR reversal 9 (IQR 5–14) h vs. 10 (IQR 7–16) h, p = 0.61]. Patients with ultimately poor outcome received more rapid INR reversal than those with favorable outcome [9 (IQR 6–14) h vs. 12 (8–19) h, p = 0.064). We find no evidence of an association between faster INR reversal and either reduced hematoma expansion or better outcome.

Keywords

Intracerebral hemorrhage Warfarin Stroke Cerebral hemorrhage Anticoagulants 

Notes

Author contribution

MA: Study concept and design; analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content; statistical expertise; study supervision; and final approval of version being published. AM: Analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; statistical expertise; and final approval of version being published. ASC: Analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; administrative, technical, or material support; and final approval of version being published. YC: Study concept and design; analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; statistical expertise; and final approval of version being published. AMA: Acquisition of the data; critical revision of the manuscript for important intellectual content; administrative, technical, or material support; and final approval of version being published. KS: Acquisition of the data; critical revision of the manuscript for important intellectual content; administrative, technical, or material support; and final approval of version being published. AV: Acquisition of the data; analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; statistical expertise; and final approval of version being published. MEG: Acquisition of the data; analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; statistical expertise; and final approval of version being published. CDA: Acquisition of the data; analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; statistical expertise; obtained funding; and final approval of version being published. SMG: Acquisition of the data; analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; statistical expertise; and final approval of version being published. JR: Study concept and design; acquisition of the data; analysis and interpretation of the data; critical revision of the manuscript for important intellectual content; obtained funding; and final approval of version being published. JNG: Study concept and design; acquisition of the data; analysis and interpretation of the data; drafting of the manuscript; critical revision of the manuscript for important intellectual content; statistical expertise; obtained funding; study supervision; and final approval of version being published.

Compliance with ethical standards

Funding

This study was funded by support from NIH NINDS K23NS086873, NIH NINDS K23AG02872605, NIH NINDS 5R01NS073344, and NIH NINDS R01NS059727.

Conflict of interest

The authors declare that they have no conflict of interest.

Human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Data

The data sets during or analyzed during the current study are available from the corresponding author on reasonable request.

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Copyright information

© SIMI 2017

Authors and Affiliations

  • Murtaza Akhter
    • 1
    • 3
  • Andrea Morotti
    • 2
  • Abigail Sara Cohen
    • 2
  • Yuchiao Chang
    • 3
  • Alison M. Ayres
    • 2
  • Kristin Schwab
    • 2
  • Anand Viswanathan
    • 2
  • Mahmut Edip Gurol
    • 2
  • Christopher David Anderson
    • 2
  • Steven Mark Greenberg
    • 2
  • Jonathan Rosand
    • 2
  • Joshua Norkin Goldstein
    • 3
  1. 1.Department of Emergency MedicineUniversity of Arizona College of Medicine–Phoenix and Maricopa Integrated Health SystemPhoenixUSA
  2. 2.Department of Neurology, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  3. 3.Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA

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