Published Online
on December 8, 2005

A more recent version of this article appeared on January 1, 2006

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Submitted on June 23, 2005
Accepted on October 19, 2005

Intracerebral Hemorrhage Associated With Oral Anticoagulant Therapy. Current Practices and Unresolved Questions

Thorsten Steiner MD, PhD^*; Jonathan Rosand MD, MSc; and Michael Diringer MD, FAHA

From the Department of Neurology, University of Heidelberg, Germany (T.S.); the Vascular and Critical Care Neurology, Massachusetts General Hospital, Boston, Mass (J.R.); and the Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University, St Louis, Mo (M.D.).

^* To whom correspondence should be addressed. E-mail: thorsten_steiner{at}med.uni-heidelberg.de.

Background and Purpose--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.

Summary of Review--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.

Key words: etiology • intracerebral hemorrhage • oral anticoagulant agents • therapy • warfarin

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