Intracranial Hematoma in Patients Receiving Warfarin –  Case Reports and Recommended Therapy


Authors: V. Přibáň 1,2;  M. Holý 3;  I. Vonke 4
Authors‘ workplace: Neurochirurgické oddělení, Nemocnice České Budějovice, a. s. 1;  Neurochirurgická klinika LF MU a FN Brno 2;  Interní oddělení, Nemocnice České Budějovice, a. s. 3;  Hematologické oddělení, Nemocnice České Budějovice, a. s. 4
Published in: Cesk Slov Neurol N 2009; 72/105(6): 570-574
Category: Case Report

Overview

Intracranial haemorrhage, whether spontaneous or the result of trauma, involves high morbidity// mortality. Older patients with medical co- morbidities often suffer from these haematomas. The authors present three case reports of intracranial haemorrhages (two of traumatic origin and one spontaneous) which involved a non‑standard approach to reversal therapy. They stress the need for rapid warfarin reversal and propose a therapeutic protocol that consists of rapid substitution of clotting factors together with urgent surgical intervention if indicated. Further, patients on oral anticoagulant therapy with intracranial haematoma should always be admitted in the centres with permanent neurosurgical services. Rapid warfarin reversal together with emergency operation in the event of clinical deterioration are conditions for the improvement of results in the treatment of intracranial haemorrhage in oral anticoagulant therapy patients.

Key words:
intracranial hemorrhage – warfarin – surgery


Sources

1. Hirsh J, Fuster V, Ansell J, Halperin JL. American Heart Association/ American College of Cardiology Foundation Guide to Warfarin Therapy. Circulation 2003; 107(12): 1692– 1711.

2. Schulman S, Beyth RJ, Kearon C, Levine MN. Hemorrhagic Complications of Anticoagulant and Thrombolytic Treatment. American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl 6): 257S– 298S.

3. Baglin TP, Keeling DM, Watson HG. Guidelines on oral anticoagulation (warfarin): third edition –  2005 update. Br J Haematol 2006; 132(3): 277– 285.

4. Gumulec J, Kessler P, Penka M, Klodová D, Králová S,Brejcha M et al. Z. Krvácivé komplikace při léčbě warfarinem 2005 [online]. Dostupné z: http:/ / www.thrombosis.cz/ sources/ Guidelines_warfarin_krvaceni_STH_XI05.pdf.

5. Wintzen AR, de Jonge H, Loeliger EA, Bots GT. The risk of intracerebral hemorrhage during oral anticoagulant treatment: a population study. Ann Neurol 1984; 16(5): 553– 558.

6. Mina AA, Bair HA, Howells GA, Bendick PJ. Complications of preinjury warfarin use in the trauma patient. J Trauma 2003; 54(5): 842– 847.

7. Karni A, Holtzman R, Bass T, Zorman G, Carter L, Rodriquez L. Traumatic head injury in the anticoagulated elderly patient: a lethal combination. Am Surg 2001; 67(11): 1098– 1100.

8. Grandhi R, Duane TM, Dechert T, Malhotra AK, Aboutanos MB, Wolffe LG et al. Anticoagulation and the elderly head trauma patient. Am Surg 2008; 74(9): 802– 805.

9. Fang MC, Go AS, Chang Y, Hylek EM, Henault LE, Jensvold NE et al. Death and disability from warfarin‑associated intracranial and extracranial hemorrhages. Am J Med 2007; 120(8): 700– 705.

10. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update. a guideline from the American Heart Association/ American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007; 38(6): 2001– 2023.

11. Baker RI, Coughlin PB, Gallus AS, Harper PL, Salem HH, Wood EM. Warfarin Reversal Consensus Group. Warfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis. Med J Aust 2004; 181(9): 492– 497.

12. Kalina M, Tinkoff G, Gbadebo A, Veneri P, Fulda G.A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy. Am Surg 2008; 74(9): 858– 861.

13. Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma 2005; 59(5): 1131– 1139.

14.Yasaka M, Minematsu K, Naritomi H, Sakata T, Yamaguchi T. Predisposing factors for enlargement of intracerebral hemorrhage in patients treated with warfarin. Thromb Haemost 2003; 89(2): 278– 283.

15. Aithal GP, Day CP, Kesteven PJ, Daly AK. Association of polymorphisms in the cytochrome P450 CYP2C9 with warfarin dose requirement and risk of bleeding complications. Lancet 1999; 353(9154): 717– 719.

16. Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med 1994; 120(11): 897– 902.

17. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma 2007; 63(3): 525– 530.

18. Go AS, Hylek EM, Phillips KA, Chang Y, Henault LE, Selby JV et al. Prevalence of diagnosed atrial fibrillation in adults: National implications for rhythm management and stroke prevention: The AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA 2001; 285(18): 2370– 235.

19. Secondary prevention in non‑rheumatic atrial fibrillation after transitransient ischaemic attack or minor stroke. EAFT (European Atrial Fibrillation Trial) Study Group. Lancet 1993; 342(8882): 1255– 1262.

20. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: A meta‑analysis. Ann Intern Med 1999; 131(7): 492– 501.

21. van Walraven C, Hart RG, Singer DE, Laupacis A, Connolly S, Petersen P et al. Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta‑analysis. JAMA 2002; 288(19): 2441– 2448.

22. Steiner T, Rosand J, Diringer M. Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions. Stroke 2006; 37(1): 256– 262.

23. Flibotte JJ, Hagan N, O’Donnell J, Greenberg SM, Rosand J. Warfarin, hematoma expansion and outcome of intracerebral hemorrhage. Neurology 2004; 63(6): 1059– 1064.

24. Lavoie A, Ratte S, Clas D, Demers J, Moore L, Martin M et al. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma 2004; 56(4): 802– 807.

25. Franko J, Kish KJ, O’Connell BG, Subramanian S, Yuschak JV. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J Trauma 2006; 61(1): 107– 110.

26. Makris M, Greaves M, Phillips WS, Kitchen S, Rosendaal FR, Preston EF. Emergency oral anticoagulation reversal: The relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy. Thromb Haemost 1997; 77(3): 477– 480.

27. Boulis N, Bobek M, Schmaier A, Hoff JT. Use of factor IX complex in warfarin related intracranial hemorrhage. Neurosurgery 1999; 45(5): 1113– 1119.

28. Lin J, Hanigan WC, Tarantino M, Wang J. The use of recombinant activated factor VII to reverse warfarin‑induced anticoagulation in patients with hemorrhages in the central nervous system: preliminary findings. J Neurosurg 2003; 98(4): 737– 740.

29. Brody DL, Aiyagari V, Shackleford AM, Diringer MN. Use of recombinant factor VIIa in patients with warfarin‑associated intracranial hemorrhage. Neurocrit Care 2005; 2(3): 263– 267.

30. Stein DM, Dutton RP, Kramer ME, Scalea TM. Reversal of coagulopathy in critically ill patients with traumatic brain injury: recombinant factor VIIa is more cost‑effective than plasma. J Trauma 2009; 66(1): 63– 75.

31. Lankiewicz MW, Hays J, Friedman KD, Tinkoff G, Blatt PM. Urgent reversal of warfarin with prothrombin complex concentrate. J Thromb Haemost 2006; 4(5): 967– 970.

Labels
Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 6

2009 Issue 6

Most read in this issue
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account