When and how should coagulopathy be reversed?
Warfarin is both a risk factor for hematoma enlargement even after 24 hours and for worse outcomes after ICH.
There are no randomized clinical trials available comparing the efficacy of different reversal agents and their impact on clinical outcome.
Consequently there is considerable variability in clinical practice.
Patients with ICH whose international normalized ratio (INR) is elevated due to oral anticoagulants should have their warfarin withheld, receive therapy to replace vitamin K–dependent factors, correct the INR, and receive intravenous vitamin K with a goal INR of <1.4.
Prothrombin complex concentrates (PCC) have not shown improved outcome compared with fresh frozen plasma (FFP) but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP.
FVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for oral anticoagulant reversal in ICH.
There is currently no specific antidote available to antagonize the effects of novel oral anticoagulants.
