Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion.
Wider use of oral anticoagulants has led to an increasing frequency of warfarin-related intracerebral hemorrhage (ICH). The high early mortality of approximately 50% has remained stable in recent decades. In contrast to spontaneous ICH, the duration of bleeding is 12 to 24 hours in many patients, offering a longer opportunity for intervention. Treatment varies widely, and optimal therapy has yet to be defined. An OVID search was conducted from January 1996 to January 2006, combining the terms warfarin or anticoagulation with intracranial hemorrhage or intracerebral hemorrhage. Seven experts on clinical stroke, neurologic intensive care, and hematology were provided with the available information and were asked to independently address 3 clinical scenarios about acute reversal and resumption of anticoagulation in the setting of warfarin-associated ICH. No randomized trials assessing clinical outcomes were found on management of warfarin-associated ICH. All experts agreed that anticoagulation should be urgently reversed, but how to achieve it varied from use of prothrombin complex concentrates only (3 experts) to recombinant factor VIIa only (2 experts) to recombinant factor VIIa along with fresh frozen plasma (1 expert) and prothrombin complex concentrates or fresh frozen plasma (1 expert). All experts favored resumption of warfarin therapy within 3 to 10 days of ICH in stable patients in whom subsequent anticoagulation is mandatory. No general agreement occurred regarding subsequent anticoagulation of patients with atrial fibrillation who survived warfarin-associated ICH. For warfarin-associated ICH, discontinuing warfarin therapy with administration of vitamin K does not reverse the hemostatic defect for many hours and is inadequate. Reasonable management based on expert opinion includes a wide range of additional measures to reverse anticoagulation in the absence of solid evidence.
Aguilar
Maria I
MI
Department of Neurology, Mayo Clinic College of Medicine, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA. aguilar.maria@mayo.edu
Hart
Robert G
RG
Kase
Carlos S
CS
Freeman
William D
WD
Hoeben
Barbara J
BJ
García
Rosa C
RC
Ansell
Jack E
JE
Mayer
Stephan A
SA
Norrving
Bo
B
Rosand
Jonathan
J
Steiner
Thorsten
T
Wijdicks
Eelco F M
EF
Yamaguchi
Takenori
T
Yasaka
Masahiro
M
D000925:Anticoagulants / Q000009:adverse effects* / Q000627:therapeutic use; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D002543:Cerebral Hemorrhage / Q000139:chemically induced / Q000453:epidemiology / Q000628:therapy*; D005167:Factor VII / Q000627:therapeutic use*; D015942:Factor VIIa; D006801:Humans; D006973:Hypertension / Q000628:therapy; D007049:Iatrogenic Disease; D010949:Plasma; D011994:Recombinant Proteins / Q000627:therapeutic use; D014859:Warfarin / Q000009:adverse effects*
D000925:Anticoagulants; D001779:Blood Coagulation Factors; D011994:Recombinant Proteins; C025667:prothrombin complex concentrates; D014859:Warfarin; D005167:Factor VII; C103587:recombinant FVIIa; D015942:Factor VIIa