Treatment of Warfarin-Associated Intracerebral Hemorrhage: Literature Review and Expert Opinion

Abstract

Steiner have served as consultants to NovoNordisk and are members of the Recombinant Factor VII ICH Study Team. All authored materials constitute the personal statements of Maj Barbara J. Hoeben and are not intended to constitute an endorsement by Wilford Hall Medical Center, Lackland AFB, or any other federal government entity.

Fluid levels in the bleeding brain: a marker for coagulopathy and hematoma expansion

“…Fluid levels in intracerebral hemorrhage have also been reported in patients receiving fibrinolysis after acute myocardial infarction [4]. In patients with anticoagulantassociated intraparenchymal hemorrhage, a careful history of anticoagulant use should be elicited, coagulation parameters checked, and reversal agents administered promptly to stabilize hematoma size and promote clotting [5].…”

Spontaneous intracranial epidural hematoma during rivaroxaban treatment

“…Nevertheless, most warfarin-associated intracerebral hemorrhage cases occur during times when the drug is in the therapeutic range (INR 2.0-3.0). 12 The Food and Drug Administration (FDA) approved rivaroxaban (Xarelto®) in 2011, a new orally administered direct factor Xa inhibitor with superior efficacy and a similar safety profile to warfarin, prescribed for stroke, systemic embolism prophylaxis in patients with non valvular atrial fibrillation, treatment, and prevention of pulmonary embolism and deep vein thrombosis. The ROCKET AF study showed that rivaroxaban had 40% lower risk of intracranial and fatal bleeding compared to warfarin.…”

The benefit of prothrombin complex concentrate in decreasing neurological deterioration in patients with warfarin-associated intracerebral haemorrhage

“…Prothrombin complex concentrates are readily available, are less expensive than rFVIIa, and have a longer half-life than rFVIIa. 1 Many international societies recommend PCC as the first-line agents for warfarin reversal in emergency situations. [9][10][11][12] Those recommendations are, however, mainly based on rapid reversal of INR by PCC.…”

“…1,2 Up to 50% of patients will have haematoma expansion within 24 hours, and the haematoma expansion time interval is more prolonged versus those with ORIGINAL ARTICLE of neurological deterioration in the prothrombin complex concentrate group (17.4% of 23 patients) versus fresh frozen plasma group (45.5% of 33 patients) [P=0.027]. In terms of the 7-day mortality, 30-day mortality, and 3-month functional outcome, prothrombin complex concentrate-treated group showed a favourable trend although the difference did not reach a statistical significance.…”