Introduction: Reversal of anticoagulation is required to mitigate the risk of intracranial bleeding prior to urgent neurosurgical procedures. New pharmacological agents, such as multifactor prothrombin complex concentrate (PCC; Kcentra®), promise rapid efficacy but may raise the probability of thrombotic complications above vitamin K infusion or administration of Fresh Frozen Plasma (FFP). In this study, we examined the rate of thrombotic complications in neurosurgical patients who received either PCC or FFP and Vitamin K before undergoing urgent surgery.
Methods: Sixty-three consecutive patients who received anticoagulation reversal for urgent neurosurgical procedures were identified between 2008-14 at a Level I trauma center. They were divided into two cohorts based on reversal method, either PCC (n = 28) or FFP/Vitamin K (n = 35). The rate of thrombotic complications within 72 hours of reversal was compared using a two-sample t-test. To minimize selection bias, a multivariate propensity score matching analysis was then used to identify a control group of FFP patients most similar to patients in the PCC group based on age, gender, trauma, altered mental status, and preexisting heart failure.
Results: Thrombotic complications were uncommon but not rare in this neurosurgical population, occurring in 8.3% of treated patients (3/63). There was no difference in thrombotic complication rate between groups, 7.14% (2/28; PCC group) vs. 2.86% (1/28; FFP group; p = ns). Propensity matching analysis verified this finding after controlling for any selection bias.
Conclusions: Thrombotic complications in neurosurgical patients requiring rapid reversal at a Level I trauma center are uncommon but not rare. New pharmacological agents have similar rates of thrombotic complications as FFP. In this limited sample, use of PCC did not pose a significant increase in risk compared with FFP in the management of intracranial bleeding.
Patient Care: Our research will improve patient care by demonstrating the safety of new pharmacological agents for anti-coagulation reversal that have more more rapid efficacy than traditional agents. Such increased efficacy without comprising safety is essential in the management of intracranial bleeding prior to urgent neurosurgical procedures.
Learning Objectives: 1. Estimate the rate of thrombotic complications in patients undergoing anticoagulation reversal (PCC, FFP and Vitamin K) and subsequent neurosurgical procedure.
2. Understand that demographics (age/gender) and risk factors for thrombosis in neurosurgical patients (trauma, altered mental status, preexisting heart failure) may result in selection bias.
3. Determine if there is an elevated rate of thrombotic complications for patients who receive PCC compared with those who receive FFP and Vitamin K.