title: Reversal of warfarin associated coagulopathy with 4-factor prothrombin complex concentrate in traumatic brain injury and intracranial hemorrhage.
abstract: Warfarin-associated intracranial hemorrhage is associated with a high mortality rate. Ongoing coagulopathy increases the likelihood of hematoma expansion and can result in catastrophic hemorrhage if surgery is performed without reversal. The current standard of care for emergency reversal of warfarin is with fresh frozen plasma (FFP). In April 2013, the USA Food and Drug Administration approved a new reversal agent, 4-factor prothrombin complex concentrate (PCC), which has the potential to more rapidly correct coagulopathy. We sought to determine the feasibility and outcomes of using PCC for neurosurgical patients. A prospective, observational study of all patients undergoing coagulopathy reversal for intracranial hemorrhage from April 2013 to December 2013 at a single, tertiary care center was undertaken. Thirty three patients underwent emergent reversal of coagulopathy using either FFP or PCC at the discretion of the treating physician. Intracranial hemorrhage included subdural hematoma, intraparenchymal hematoma, and subarachnoid hemorrhage. FFP was used in 28 patients and PCC was used in five patients. International normalized ratio at presentation was similar between groups (FFP 2.9, PCC 3.1, p=0.89). The time to reversal was significantly shorter in the PCC group (FFP 256 minutes, PCC 65 minutes, p<0.05). When operations were performed, the time delay to perform operations was also significantly shorter in the PCC group (FFP 307 minutes, PCC 159 minutes, p<0.05). In this preliminary experience, PCC appears to provide a rapid reversal of coagulopathy. Normalization of coagulation parameters may prevent further intracranial hematoma expansion and facilitate rapid surgical evacuation, thereby improving neurological outcomes.
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
authors: Vijay
authors: V
authors: Yanamadala
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA. Electronic address: walcott.brian@mgh.harvard.edu.
authors: Brian P
authors: BP
authors: Walcott
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
authors: Peter E
authors: PE
authors: Fecci
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
authors: Peter
authors: P
authors: Rozman
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
authors: Jay I
authors: JI
authors: Kumar
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
authors: Brian V
authors: BV
authors: Nahed
authors: Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA.
authors: Brooke
authors: B
authors: Swearingen
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D000931:Antidotes / Q000494:pharmacology / Q000627:therapeutic use*; D001779:Blood Coagulation Factors / Q000494:pharmacology / Q000627:therapeutic use*; D001930:Brain Injuries / Q000188:drug therapy*; D006470:Hemorrhage / Q000139:chemically induced / Q000188:drug therapy; D006801:Humans; D019934:International Normalized Ratio; D020300:Intracranial Hemorrhages / Q000139:chemically induced / Q000188:drug therapy*; D010949:Plasma; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D013122:Spinal Diseases / Q000188:drug therapy; D013345:Subarachnoid Hemorrhage / Q000188:drug therapy; D062606:Tertiary Care Centers; D014859:Warfarin / Q000009:adverse effects* / Q000037:antagonists & inhibitors / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D000931:Antidotes; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates; D014859:Warfarin
keywords: Fresh frozen plasma; Intracranial hemorrhage; Prothrombin complex concentrate; Subdural hematoma; Warfarin