Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions.
OBJECTIVE
Life-threatening intracranial hemorrhage, predominantly intracerebral hemorrhage (ICH), is the most serious complication of oral anticoagulant therapy (OAT), with mortality in excess of 50%. Early intervention focuses on rapid correction of coagulopathy in order to prevent continued bleeding.


RESULTS
This article reviews the epidemiology of OAT-associated ICH (OAT-ICH), and current treatment options, with the aim of providing a framework for future studies of unresolved questions. A number of acute treatments are available, but all have a significant risk of inducing thrombosis and other side effects, and vary in their rapidity of effect: vitamin K (very slow response time), fresh frozen plasma (slow response time, large volume of fluid required, transfusion-related acute lung injury), prothrombin complex concentrates, and recombinant activated factor VII. Current practice is to administer a combination of vitamin K and either fresh frozen plasma or prothrombin complex concentrates; the occasional use of recombinant activated factor VII has been reported. No prospective study has addressed the efficacy of, or outcomes from, the use of these practices.


CONCLUSIONS
Current management of OAT-ICH is varied and not based on evidence from randomized controlled trials. Well-designed clinical trials are essential if we are to identify the effective acute treatments for OAT-ICH that are urgently needed.
Steiner
Thorsten
T
Department of Neurology, University of Heidelberg, Germany. thorsten_steiner@med.uni-heidelberg.de
Rosand
Jonathan
J
Diringer
Michael
M
D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000628:therapy*; D002986:Clinical Trials as Topic; D015942:Factor VIIa / Q000378:metabolism; D006470:Hemorrhage / Q000139:chemically induced / Q000628:therapy; D006801:Humans; D011994:Recombinant Proteins / Q000627:therapeutic use; D012306:Risk; D013927:Thrombosis / Q000209:etiology; D014812:Vitamin K / Q000378:metabolism
D000925:Anticoagulants; D011994:Recombinant Proteins; D014812:Vitamin K; D015942:Factor VIIa