Warfarin Reversal in Anticoagulant-Associated Intracerebral Hemorrhage
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Warfarin Reversal in Anticoagulant-Associated Intracerebral Hemorrhage Joshua N. Goldstein Æ Jonathan Rosand Æ Lee H. Schwamm
Published online: 23 January 2008 Ó Humana Press Inc. 2008
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
J. N. Goldstein Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA J. Rosand L. H. Schwamm (&) Department of Neurology, Massachusetts General Hospital, Harvard Medical School, ACC 720, 55 Fruit Street, Boston, MA 02114, USA e-mail: [email protected]
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. Keywords Cerebral hemorrhage Warfarin Plasma Blood coagulation factors Factor VII
Intracerebral Hemorrhage: Hematoma Formation and Expansion Intracerebral hemorrhage (ICH) is the deadliest form of stroke, with a mortality rate of 23–60% [1–4]. The majority of survivors suffer long-term neurologic deficits and are unable to return to independent levels of function [1]. While hematoma formation causes injury by multiple mechanisms [5–8], the most significant factor influencing outcome is mass effect from the hematoma itself [9, 10]. Therefore, interventions that minimize ongoing bleeding are likely to be critical for improving outcomes. Formation of the hematoma can be a dynamic process. Continued bleeding is surprisingly common after presentation, highlighting a potential opportunity for intervention. Of patients presenting within 3 h of symptom onset, 26% develop significant expansion over the first hour,
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