Treatment of Coagulopathy in Intracranial Hemorrhage

Abstract

Intracranial hemorrhage (ICH) complicated by coagulopathy is a medical emergency, which can delay neurosurgical intervention, lead to larger hematoma size, and increase mortality until the coagulopathy is corrected. Prompt recognition of coagulopathy during ICH is essential for correct, rapid treatment to reduce ongoing bleeding and improve survival. The proper treatment of a coagulopathic ICH patient is centered on rapid identification of the coagulopathic defect and correction of the underlying coagulopathy to stop acute bleeding. Patients with coagulopathic ICH require admission to a neuro-intensive unit care with management of airway, oxygenation, and systemic arterial and cerebral perfusion pressure; optimization of serum glucose; aggressive treatment of fever; and rehabilitation. Once the coagulopathic defect is reversed, some patients benefit from emergent neurosurgical intervention to prevent secondary brain injury from raised intracranial pressure, hydrocephalus, or mass effect. The management of ICH patients prescribed common antithrombotics such as aspirin, clopidogrel, warfarin, or heparin, as well as thrombolytic agents such as tissue plasminogen activator, is the focus of this review.

Diagnosis and Management of Acute Intracerebral Hemorrhage

“…OAT is associated with higher baseline ICH volume, increased risk of hematoma expansion and poor outcome 28 . Coagulopathy correction is aimed at preventing continued bleeding.…”

Progressing haemorrhagic stroke: categories, causes, mechanisms and managements

“…However, because warfarin may only contribute to rather than cause a role in the pathogenesis of ICH [146], discontinuing warfarin therapy with the administration of vitamin K is not sufficient. PCC [5, 24], rFVIIa [5], or FFP [60] are often considered [3, 4, 107]. Schlunk et al [148] compared rFVIIa and PCC use in experimental warfarin-associated ICH and showed that they both could reduce the haematoma enlargement, with no significant difference in the reduction.…”

“…For anticoagulants, such as dabigatran, rivaroxaban or lepirudin, the previous antithrombotic therapy could also be applied, although there is no consensus for the treatment protocol [3, 95]. Because the role of antiplatelets in ICH has not been established, there is no recommended therapy for reversal, whereas the application of desmopressin acetate was reported by several researchers [3].…”

“…Because the role of antiplatelets in ICH has not been established, there is no recommended therapy for reversal, whereas the application of desmopressin acetate was reported by several researchers [3]. …”

The prognostic value of thrombelastography in identifying neurosurgical patients with worse prognosis

“…Coagulopathy can not only be induced by anticoagulant medication [4] or extensive treatment with intravenous fluids [2], but can also origin from hyper activation of coagulation with subsequent consumption of coagulation factors and platelets [5,6]. Coagulopathy is primarily diagnosed by measurements of prothrombin time (PT) or International Normalized Ratio (INR), activated partial thromboplastine time (APTT) and/or platelet count.…”