title: International normalised ratio normalisation in patients with coumarin-related intracranial haemorrhages--the INCH trial: a randomised controlled multicentre trial to compare safety and preliminary efficacy of fresh frozen plasma and prothrombin complex--study design and protocol.
abstract: BACKGROUND
  Intracerebral haemorrhage is the most feared complication in patients who are on treatment with vitamin K antagonists. Vitamin K antagonist related intracerebral haemorrhage occurs in about 10% of patients. Intracerebral haemorrhage has the worst prognosis of all subtypes of stroke including spontaneous intracerebral haemorrhage, and a mortality rate of up to about 65%. The higher rate of haematoma expansion due to rebleeding is thought to be responsible for the higher mortality. Current international treatment recommendations include fresh frozen plasma and prothrombin complex concentrate. It is known that these substances lower the international normalised ratio, and thus it is assumed that normalisation of coagulopathy may lead to haemostasis and reduction of rebleeding. However, the issue of whether to use fresh frozen plasma or prothrombin complex concentrate for urgent reversal of vitamin K antagonists is unresolved: safety and efficacy of these treatments have never been studied in a randomised controlled trial. Our questions are: how effective are the two substances in normalisation of the international normalized ratio? How feasible is it to apply either of these treatments in an acute situation? What is the safety profile of each of these substances? Is there a difference in haematoma growth and clinical outcome?
  
  
  METHODS
  We designed a prospective, randomised, controlled multicentre trial to compare biological efficacy and safety of fresh frozen plasma and prothrombin complex concentrate in vitamin K antagonist related intracerebral haemorrhage. The study is observer-blinded for laboratory, neuroradiological, and clinical outcomes. Patients will be included if a computed tomography scan shows an intraparenchymal or subdural haematoma within 12 h after onset of symptoms, if the patient is on treatment with vitamin K antagonists, and the international normalized ratio is ≥2. Primary endpoint is the normalisation of the international normalized ratio (≤1·2) within three-hours after the start of antagonising therapy. Main exclusion criteria are secondary intracerebral haemorrhage, other known coagulopathies, and known acute ischaemic events.
  
  
  CONCLUSIONS
  We discuss the rationale of our trial on the basis of the current recommendations and specific aspects of trial design as, time window, choice of endpoints, dosing of fresh frozen plasma and prothrombin complex concentrate, monitoring and analysis of safety parameters, and rescue treatment.
  
  
  CONCLUSIONS
  This will be the first prospective trial comparing fresh frozen plasma and prothrombin complex concentrate in the indication of vitamin K antagonist related intracerebral hemorrhage. Recruitment of subjects started in August 2009. Until now, 19 patients have been included.
authors.affiliation: Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany. thorsten_steiner@med.uni-heidelberg.de
authors.forename: Thorsten
authors.initials: T
authors.lastname: Steiner
authors.forename: Anja
authors.initials: A
authors.lastname: Freiberger
authors.forename: Martin
authors.initials: M
authors.lastname: Griebe
authors.forename: Johannes
authors.initials: J
authors.lastname: Hüsing
authors.forename: Boris
authors.initials: B
authors.lastname: Ivandic
authors.forename: Rainer
authors.initials: R
authors.lastname: Kollmar
authors.forename: Thomas
authors.initials: T
authors.lastname: Pfefferkorn
authors.forename: Katja E
authors.initials: KE
authors.lastname: Wartenberg
authors.forename: Christian
authors.initials: C
authors.lastname: Weimar
authors.forename: Michael
authors.initials: M
authors.lastname: Hennerici
authors.forename: Sven
authors.initials: S
authors.lastname: Poli
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects*; D003374:Coumarins / Q000009:adverse effects*; D023381:Endpoint Determination; D005260:Female; D006408:Hematoma, Subdural / Q000150:complications / Q000628:therapy; D006487:Hemostasis / Q000502:physiology; D006801:Humans; D019934:International Normalized Ratio; D020300:Intracranial Hemorrhages / Q000097:blood* / Q000139:chemically induced* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D010949:Plasma; D011446:Prospective Studies; D011516:Prothrombin / Q000009:adverse effects* / Q000627:therapeutic use*; D012107:Research Design; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed; D014812:Vitamin K / Q000037:antagonists & inhibitors; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D003374:Coumarins; D014812:Vitamin K; D011516:Prothrombin