Use of Prothrombin Complex Concentrate for Vitamin K Antagonist Reversal before Surgical Treatment of Intracranial Hemorrhage

Abstract

Background: Oral anticoagulant therapy (OAT) is used to prevent/treat thromboembolism. Major bleeding is common in patients on OAT; eg, warfarin increases intracranial hemorrhage (ICH) risk.

Case: A 71-year-old male on warfarin (to reduce stroke risk) presented at Accident and Emergency Minor Injuries Unit with headache after reportedly sounding 'drunk'. On triage, the patient appeared lucid and well. However, International Normalized Ratio (INR) was 4.1. Head computed tomography (CT) indicated a large right-sided subdural hematoma. Prothrombin complex concentrate (PCC; Beriplex(®) P/N, CSL Behring) with vitamin K normalized the INR within minutes of administration. The patient underwent neurosurgery without complications, and was discharged after 5 days, with no residual neurological symptoms.

Conclusions: ICH patients can present with no neurological signs. In OAT patients with headache, INR must be established; if ≥3.0, normalization of INR and head CT are essential. PCC is the best option to rapidly reverse anticoagulation and correct INR pre-surgery.

Keywords: Beriplex® P/N; International Normalized Ratio; anticoagulation reversal; computed tomography; intracranial hemorrhage; prothrombin complex concentrate.

Figure 1.

Computed tomography indicated a large right-sided acute on chronic subdural hematoma (maximum depth, 1.9 cm) occupying the frontal, parietal and temporal convexities, and a possible small subarachnoid hemorrhage.

Figure 2.

Management algorithm (A) and prothrombin complex concentrate (PCC) request form (B) implemented at Maidstone and Tunbridge Wells NHS Trust, UK to help Accident and Emergency staff in providing PCC for warfarin reversal. Abbreviations: CT, computed tomography; DIC, disseminated intravascular coagulation; GI, gastrointestinal; Hb, hemoglobin; INR, International Normalized Ratio; i.v., intravenous; mmHg, millimeters of mercury; NHS, National Health Service; PCC, prothrombin complex concentrate.

Figure 2.

Management algorithm (A) and prothrombin complex concentrate (PCC) request form (B) implemented at Maidstone and Tunbridge Wells NHS Trust, UK to help Accident and Emergency staff in providing PCC for warfarin reversal. Abbreviations: CT, computed tomography; DIC, disseminated intravascular coagulation; GI, gastrointestinal; Hb, hemoglobin; INR, International Normalized Ratio; i.v., intravenous; mmHg, millimeters of mercury; NHS, National Health Service; PCC, prothrombin complex concentrate.