Prothrombin Complex Concentrates Use in Intracerebral Hemorrhage
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A 65-year-old man on warfarin for atrial fibrillation was found down, with Glasgow coma scale score =6. Head computed tomographic scan reveals a 45 cc right thalamic hemorrhage with intraventricular extension. International normalized ratio (INR) =1.9.
Should he be treated with prothrombin complex concentrates (PCCs)?
Should PCCs be routinely used to reverse warfarin-related coagulopathy in patients presenting with intracerebral hemorrhage (ICH)?
Yes: PCCs Should Be Used
Sven Poli and Florian Härtig
We would treat with 4-factor PCCs because otherwise—with an INR of 1.9—there is a high risk of further expansion of an already large ICH. Without reversal of the anticoagulant effects of warfarin, the patient’s life is at stake. At age 65 years, he has a reasonable chance to recover from a right-sided ICH if treated early and aggressively. In our eyes, early withdrawal of care is not an option!
Compared with spontaneous ICH, warfarin-associate ICH (WICH) is associated with an increased risk of hematoma expansion and subsequently higher morbidity and mortality.1 Achieving rapid hematoma stabilization must, therefore, be the therapeutic goal in this case. It is promoted most effectively by administering PCCs, while the risk of prothrombotic effects is low.2 Because of ventricular involvement of the bleed, the patient is at a high risk of developing occlusive hydrocephalus. This may warrant placement of an external ventricular drain, which should only be undertaken when the INR is within normal range. INR must be monitored closely; ideally shortly after application of 30 U of PCCs per kilogram of body weight and then at least daily until it is definitely stabilized at normal levels. Within the first 3 hours, we would readminister PCCs if the INR remains elevated—the same dose if the INR is ≥2 or 10 U/kg if the INR is >1.2. For sustained reversal effect, we would also administer 10 mg of vitamin K intravenously during or shortly …