Spontaneous (non-traumatic) intracerebral hemorrhage (ICH) is a type of stroke caused by bleeding into the brain.
ICH typically causes sudden headache with stroke like symptoms.
ICH accounts for 20% of all strokes.
The mortality rate of ICH is 40%, and more than 20% of survivors are left with significant disability. Death and disability is more common with larger or expanding bleeds.
ICH is more common in patients who are taking blood thinners like warfarin (Coumadin).
Warfarin associated ICH is more likely to expand from continued bleeding leading to a worse outcome or death, so it is very important to reverse the effects of warfarin as quickly as possible in these patients.
An injection of Vitamin K will reverse the effects of warfarin, but it takes 12-24 hours to work.
Fresh frozen plasma (FFP) will reverse the effects of warfarin more quickly than vitamin K, and this has been the standard treatment for warfarin associated ICH, but FFP is a blood product that requires cross-matching and has to be thawed out and administered slowly.
Studies have shown that many patients treated with Vitamin K and FFP have not yet had the effects of warfarin completely reversed even by 24 hours after admission, and are still therefore at risk for hematoma expansion, death and disability.
Prothrombin Complex (PCC) is a new concentrated plasma protein product that can given by immediate intravenous injection, and along with Vitamin K and a small amount of FFP reverses the effects of warfarin within minutes, preventing ICH expansion and improving survival in ICH patients.
We now have PCC (Profilnine) on formulary at Monmouth Medical Center for this situation.
A 75 year old hypertensive woman who was taking warfarin because of previous stroke was brought to our emergency room with headache and confusion. A brain CT showed ICH and her INR was modestly elevated at 1.7.
She was appropriately given 10mg of Vitamin K, 25U/Kg of Profilnine and 2 units of FFP, her INR was normalized within hours, and she did very well clinically, with some evidence of ICH resolution on a follow-up CT scan 2 days later.
This favorable outcome was the direct result of great communication and cooperation between our emergency room, ER and ICU nursing staff, pharmacy and physicians with regard to this new approach for treating warfarin associated ICH.
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