title: The practical management of intracerebral hemorrhage associated with oral anticoagulant therapy.
abstract: Oral anticoagulant-associated intracerebral hemorrhage is increasing in incidence and is the most feared complication of therapy with vitamin K1 antagonists. Anticoagulant-associated intracerebral hemorrhage has a high risk of ongoing bleeding, death, or disability. The most important aspect of clinical management of anticoagulant-associated intracerebral hemorrhage is represented by urgent reversal of coagulopathy, decreasing as quickly as possible the international normalized ratio to values ≤1·4, preferably ≤1·2, together with life support and surgical therapy, when indicated. Protocols for anticoagulant-associated intracerebral hemorrhage emphasize the immediate discontinuation of anticoagulant medication and the immediate intravenous administration of vitamin K1 (mean dose: 10-20 mg), and the use of prothrombin complex concentrates (variable doses calculated estimate circulating functional prothrombin complex) or fresh-frozen plasma (15-30 ml/kg) or recombinant activated factor VII (15-120 μg/kg). Because of cost and availability, there is limited randomized evidence comparing different reversal strategies that support a specific treatment regimen. In this paper, we emphasize the growing importance of anticoagulant-associated intracerebral hemorrhage and describe options for acute coagulopathy reversal in this setting. Additionally, emphasis is placed on understanding current consensus-based guidelines for coagulopathy reversal and the challenges of determining best evidence for these treatments. On the basis of the available knowledge, inappropriate adherence to current consensus-based guidelines for coagulopathy reversal may expose the physician to medico-legal implications.
authors.affiliation: Internal Medicine, Cecina Hospital, Cecina, Italy Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy. luca.masotti@tin.it
authors.forename: Luca
authors.initials: L
authors.lastname: Masotti
authors.forename: Mario
authors.initials: M
authors.lastname: Di Napoli
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Godoy
authors.forename: Daniela
authors.initials: D
authors.lastname: Rafanelli
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Liumbruno
authors.forename: Nicholas
authors.initials: N
authors.lastname: Koumpouros
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Landini
authors.forename: Alessandro
authors.initials: A
authors.lastname: Pampana
authors.forename: Roberto
authors.initials: R
authors.lastname: Cappelli
authors.forename: Daniela
authors.initials: D
authors.lastname: Poli
authors.forename: Domenico
authors.initials: D
authors.lastname: Prisco
mesh_terms: D000284:Administration, Oral; D000465:Algorithms; D000925:Anticoagulants / Q000008:administration & dosage / Q000494:pharmacology / Q000627:therapeutic use*; D002543:Cerebral Hemorrhage / Q000188:drug therapy* / Q000601:surgery; D015942:Factor VIIa / Q000627:therapeutic use; D017408:Guidelines as Topic; D006801:Humans; D019635:Neurosurgical Procedures; D010949:Plasma; D011516:Prothrombin / Q000627:therapeutic use; D018570:Risk Assessment; D020521:Stroke / Q000188:drug therapy / Q000209:etiology; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D000925:Anticoagulants; D014812:Vitamin K; D011516:Prothrombin; D015942:Factor VIIa