Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage

Objective: Intracranial hemorrhage in patients receiving oral anticoagulant (OAC) therapy is associated with poor neurological outcome. Prothrombin complex concentrate (PCC) is the gold-standard therapy to normalize hemostasis but remains underused. Ultra-rapid reversal of anticoagulation could reduce the time to biological and surgical hemostasis, and might improve outcome. We report the use of bolus infusions of PCC to immediately reverse anticoagulation and allow for urgent neurosurgical care. Design: Prospective, observational study. Setting: Neurosurgical intensive care unit, university hospital. Patients and particicpants: Eighteen patients with OAC-associated intracranial hemorrhage requiring urgent neurosurgical intervention. Interventions: All patients received 20 UI/kg of PCC as an intravenous bolus infusion (3 min) and 5 mg of enteral vitamin K. Surgery was started immediately, without waiting for blood sample results. Measurements and results: Serial blood samples were performed to assess prothrombin time. Coagulation was considered normal when the international normalized ratio was <= 1.5. All patients, including nine who were over-anticoagulated, had complete reversal of anticoagulation immediately after the bolus of PCC. No hemorrhagic or thrombotic adverse effect was observed intra- or postoperatively. Conclusions: A bolus infusion of PCC completely reverses anticoagulation within 3 min. Neurosurgery can be performed immediately in OAC-related intracranial hemorrhage. This study shows that OAC-treated patients can be managed as rapidly as non-anticoagulated patients.