Abstract
Warfarin-related intracerebral hemorrhage (WICH) is a devastating stroke subtype and represents a medical and neurosurgical emergency with a 1-month mortality of approximately 50%. Warfarin is commonly prescribed to prevent ischemic stroke in patients with atrial fibrillation and to prevent pulmonary embolism (PE) in patients with deep vein thrombosis (DVT). Owing to the aging population and the increased incidence of atrial fibrillation with age and subsequent warfarin use, the incidence of WICH is expected to rise in the future. When WICH occurs, immediate discontinuation of warfarin and simultaneous rapid warfarin-reversal remain the first-line interventions, sometimes with neurosurgical intervention. The optimal agent for the most rapid warfarin anticoagulation reversal remains to be defined owing to the lack of prospective randomized trials. We review current literature about WICH pathogenesis, risk factors, acute management strategies and prospects for future research for this devastating neurologic emergency.
Financial & competing interests disclosure
William D Freeman acknowledges research funding provided in part by the Robert H and Clarice Smith/ML Simpson Foundation Trust. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
Notes
Adapted from Citation[59].
Adapted from Citation[103].
*We consent, prescribe and document rFVIIa use in this setting. Patients or their legal representatives are informed regarding potential benefit, the potential for thromboembolic complications and issues regarding cost. This is an ‘off-label’ indication for rFVIIa.
FFP: Fresh frozen plasma; INR: International Normalized Ratio; PCC: Prothrombin complex concentrate; rFVIIa: Recombinant factor VIIa.