Reversal of Antithrombotics in Intracranial Hemorrhage
Recommendations
VKA Reversal
(1) We recommend discontinuing vitamin K antagonists when intracranial hemorrhage is present or suspected.
(GPS, )(2) We recommend urgent reversal of vitamin K antagonists in patients with intracranial hemorrhage with the following considerations:
(S, M)(b) We recommend assessing risks and benefits when considering VKA reversal in intracranial hemorrhage patients with concurrent symptomatic or life-threatening thrombosis, ischemia, heparin-induced thrombocytopenia, or DIC.
(3) We recommend administration of Vitamin K to ensure durable reversal of INR following VKA-associated intracranial hemorrhage. Vitamin K should be dosed as soon as possible or concomitantly with other reversal agents.
(S, M)(a) We suggest one dose of Vitamin K 10 mg IV. Subsequent treatment should be guided by follow-up INR.
(b) If repeat INR is still elevated≥1.4 within the first 24–48 h after reversal agent administration, we suggest redosing with vitamin K 10 mg IV.
(GPS, )(4) We recommend administering 3-factor or 4-factorprothrombin complex concentrates (PCC) rather than fresh frozen plasma (FFP) to patients with VKA-associated intracranial hemorrhage and INR ≥1.4.
(S, M)(a) We suggest the use of 4-factor PCC over 3-factor PCC.
(b) We suggest initial reversal with PCC alone (either 3- or 4- factor) rather than combined with FFP or rFVIIa.
(C, L)(c) We recommend that PCC dosing should be weight-based and vary according to admission INR and type of PCC used.
(d) We recommend repeating INR testing soon after PCC administration (15–60 min), and serially every 6–8 h for the next 24–48 h. Subsequent treatment should be guided by follow-up INR, with consideration given to the fact that repeat PCC dosing may lead to increased thrombotic complications and risk of DIC.
(e) If the repeat INR is still elevated ≥1.4 within the first 24–48 h after initial PCC dosing, we suggest further correction with FFP.
(C, L)(5) We recommend against administration of rFVIIa for the reversal of VKA.
(S, L)(6) If PCCs are not available or contraindicated, alternative treatment is recommended over no treatment.
(S, M)(a) Treatment with FFP and Vitamin K is recommended over no treatment.
(S, M)(b) We suggest dosing FFP at 10–15 ml/kg IV along with one dose of vitamin K 10 mg IV.
(C, L)Overview
Title
Reversal of Antithrombotics in Intracranial Hemorrhage
Authoring Organizations
Neurocritical Care Society
Society of Critical Care Medicine