Clinical management of spontaneous intracranial haemorrhage associated with oral anticoagulants: a case series

Introduction: Intracranial haemorrhage (ICH) is associated with high mortality and morbidity, and for this reason it is the most feared complication of oral anticoagulant therapy (OAT). Recommendations are available for the immediate reversal of OAT, but these measures are not always used uniformly and rapidly. The aim of this study was to critically review the treatment of spontaneous OAT-related ICH in our hospital.
Materials and methods: We retrospectively analyzed the medical records of patients admitted to our ward between January 2006 and January 2010 for spontaneous OAT-related ICH.
Results: In the analyzed period, 15 patients were hospitalized for OAT-related ICH (supratentorial in 66.5%, infratentorial in 20%, acute subdural hematoma in 13.5%). In 66.5% of the patients, the INR on arrival was within the therapeutic range. In 60% of the cases, the Glasgow Coma Scale (GCS) on arrival was > 8/15. Three-factor prothrombin complex concentrate (PCC) was administered in 80% of the cases, and 30% of patients received fresh frozen plasma (FFP) and recombinant activated factor VII (FVIIra). One patient received PCC plus PFC, and another received PCC with FVIIra. FFP alone was used in 13.5% of the patients. All of the patients received intravenously administered vitamin K1. Treatment was started in the Emergency Room in 33.5% of the cases; in the other 66.5% it began on our ward. In 66.5% of the patients, the treatment was effective in reversing OATwithin 8 hours. In 2 cases, the hematoma was surgically evacuated, and the patients survived. Total mortality for OAT-related ICH was 46.5% (32.9% in non-OAT-related ICH). In 71.5% of the patients with OAT-related haemorrhages, death occurred within 48 hours of arrival. Sixty percent of the patients with ICH > 60 cm3 (20% in patients with ICH < 60 cm3) and 100% of those with GCS < 7/15 died. For survivors, the median modified Rankin Scale at discharge was 3. All survivors were still alive at 3 months after discharge.
Conclusions: Our study shows that in ICH associated with OAT, mortality is related to the size of the hematoma and to the GCS. Our study confirms that treatment of OAT-related ICH varies and is sometimes delayed. Management protocols for ICH-OATshould be implemented in clinical settings.