Intracranial Hemorrhage on Warfarin: Time to Reversal Is of the Essence (S16.008)

Background: Anticoagulation reversal is recommended for patients with intracerebral hemorrhage (ICH) on vitamin K antagonists or novel anticoagulants. Guidelines vary and standardized protocols are inconsistent. While our institution has guidelines indicating appropriate products for reversal, no specific timeline is indicated. ICH volume is known to increase by approximately 38[percnt] within the first 3 hours. Increase in hemorrhage size may be heightened in patients on anticoagulation without timely reversal. Objective: Identify a specified window for reversal of Vitamin K antagonists, in which ICH volume remained below the average growth in a control population on follow up imaging. Methods: Retrospective chart review of patients at Henry Ford Hospital from 2013-2014 with the diagnosis of ICH. Patients were excluded if they did not have follow up scans, if they underwent surgical intervention which precluded calculation of hemorrhage volume on subsequent scans, or had < 1cc initial hemorrhage volume. Results: Forty-five control patients were identified: Mean age 66.8 (44-92), GCS on admission 11 (3-15), ICH volume on admission 20.28cc, ICH volume on repeat scan 23.94cc, change in ICH volume 23.94[percnt], and time between initial and stability scans was 1150 minutes. Eleven patients on vitamin K antagonists (warfarin) were identified who underwent reversal with 4-factor prothrombin complex concentrate. Mean age 74.3 (58-88), GCS on admission 11 (3-15), ICH volume on admission 31.81cc, ICH volume on repeat scan 42.42cc, and time between initial and stability scans was 630 minutes. Mean time to PCC drug administration 221 minutes (52-805). Patients who had PCC administered before 195 minutes had a mean change in ICH volume of 16.95[percnt]. Patients who had reversal completed after the 195 minute mark had an mean change in ICH volume of 60.28[percnt]. (P value= 0.0032). Conclusions: We propose a "recommended reversal time" of less than 200 minutes for Vitamin K antagonists. Disclosure: Dr. Mehta has nothing to disclose. Dr. Jones has nothing to disclose. Dr. Ruiz Cuero has nothing to disclose. Dr. Wellwood has nothing to disclose. Dr. Rehman has nothing to disclose. Dr. Mitsias has nothing to disclose. Dr. Varelas has received personal compensation for activities with UCB Pharma as an advisory board member.