The Anticoagulated Patient in the Acute Phase of Intracerebral Hemorrhage

Figure 69.1. Enlargement of hematoma due to warfarin anticoagulation. 64 year old woman with hypertension and atrial fibrillation, receiving long-term warfarin oral anticoagulation for cardioembolic stroke prevention. Initial INR 4.5. Panel A demonstrates the non-contrast head CT scan at initial presentation, which likely represents a hypertensive ICH occurring while the patient was being treated with warfarin. At this time she was alert, with normal language, and a mild right hemiparesis. Fresh frozen plasma was ordered, cross-matched, thawed and intravenous administration begun. 10 hours later the patient deteriorated due to massive hematoma expansion (Panel B) and later died.

Figure 69.2. Proposed algorithm for hyperacute warfarin reversal.

69.6 Conclusions

Anticoagulant-associated intracranial hemorrhage is increasing in incidence. Because it is associated with high risk of ongoing bleeding, death, or disability, urgent reversal of coagulopathy is of the highest priority. Several agents are available, all with various positive and negative attributes. All protocols for warfarin-related intracranial hemorrhage emphasize immediate cessation of the anticoagulant medication and immediate administration of vitamin K (usually intravenously). The use of PCC or rFVIIa may reverse coagulopathy more rapidly than FFP alone, but randomized trials testing this have yet to be performed. Furthermore, cost and availability of these agents may limit their widespread use.

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