Introduction: Warfarin–associated intracerebral hemorrhage (ICH) is often results in poor prognosis due to hematoma expansion under uncorrected coagulopathy. Recently, rapid reversal of vitamin K antagonist by four-factor prothrombin complex concentrates (4F-PCC) was shown to be superior to fresh frozen plasma (FFP), in terms of rapid prothrombin time-internal normalized ratio (PT-INR) reversal and effective hemostasis for urgent surgical or invasive procedures, but PCC has still not been approved by Ministry of Health, Labor and Welfare in Japan. The aim of this study was to elucidate the effect of 4F-PCC in comparison with FFP for hematoma expansion and clinical outcome after warfarin-associated ICH.
Methods: We retrospectively reviewed 57 patients with ICH who was taking warfarin at the initial diagnosis of it. Baseline characteristics such as age, gender, location of hematoma, hematoma volume, and various hematological factors such as platelet count was collected from the medical records. The extent of hematoma expansion calculated through serial head CT scans, modified Rankin scale (mRS) at discharge, and adverse events attributable to 4F-PCC or FFP were compared between those treated with 4F-PCC (4F-PCC group) and fresh frozen plasma (FFP group).
Results: In the 4F-PCC group, PT–INR was corrected from 2.65±0.72 to 1.41±0.14 (p<0.01) within 10 to 90 minutes. Hematoma expansion more than 40% of its volume occurred significantly less in the 4F-PCC group (4F-PCC group 0% vs. FFP group 24.2%, p=0.015). The number of cases with mRS 5 or 6 at discharge were nonsignificantly smaller in the PCC group (12.5% vs. 33.3%, p=0.11). Two cerebral embolisms(8%) were noted in the PCC group within 4 days after PCC administration.
Conclusions: Hematoma expansion was significantly less in the PCC group and that might be associated with better prognosis in the patients with warfarin–associated ICH. However, adverse effects such as subsequent cerebral embolism should be monitored.
Patient Care: The results of this study improve clinical outcome after warfarin-induced ICH.
Learning Objectives: By the conclusion of this session, participants should be able to describe the importance of 4F-PCC for the patients with warfarin-induced ICH.