Treatment of Spontaneous Intracerebral Hemorrhage on Vitamin K Antagonist with INR ≥1.3

This protocol addresses spontaneous intracerebral hemorrhage (ICH) occurring in patients on a vitamin K antagonist — such as warfarin — who present with an international normalized ratio (INR) of 1.3 or greater.

Clinical Scenario

          Spontaneous ICH in the setting of vitamin K antagonist therapy with a coagulopathic INR (≥1.3) carries an elevated risk of hematoma expansion. The degree of INR elevation influences the choice and urgency of the reversal strategy.
        

Treatment Approach

Management centers on immediate discontinuation of anticoagulation and rapid reversal using coagulation factor replacement, with vitamin K as part of the reversal strategy — the complete algorithm is in the full protocol.

Clinical Goals

Rapid correction of INR (INR of 1.2 or less within 3 hours of starting treatment) and limitation of hematoma expansion.

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References

DOI: 10.1161/STR.0000000000000407

In patients with anticoagulant-associated spontaneous ICH, anticoagulation should be discontinued immediately and rapid reversal of anticoagulation should be performed as soon as possible after diagnosis of spontaneous ICH to improve survival.

In patients with VKA-associated spontaneous ICH and INR ≥2.0, 4-factor (4-F) prothrombin complex concentrate (PCC) is recommended in preference to fresh-frozen plasma (FFP) to achieve rapid correction of INR and limit HE.

In patients with VKA-associated spontaneous ICH with INR of 1.3 to 1.9, it may be reasonable to use PCC to achieve rapid correction of INR and limit HE.

In patients with VKA-associated spontaneous ICH, intravenous vitamin K should be administered directly after coagulation factor replacement (PCC or other) to prevent later increase in INR and subsequent HE.

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