Anticoagulation Reversal with Prothrombin Complex Concentrate in Aneurysmal Subarachnoid Hemorrhage

Intracerebral hemorrhage is a well-recognized complication of anticoagulation therapy. However, there are only a few reports that address the management of aneurysmal subarachnoid hemorrhage (aSAH) in anticoagulated patients.

We report on our experiences with the use of prothrombin complex concentrate (PCC) for rapid anticoagulation reversal in aSAH.

We retrospectively analyzed our institutional database of consecutive patients who received PCC between February 2006 and August 2014 (n > 1000). Data from all anticoagulated patients referred to our hospital for aSAH and those who received PCC were included in this analysis. Patient characteristics as well as treatment modalities were analyzed, with specific focus on results of laboratory examination, PCC administration and bleeding, and thromboembolic complications during the later course.

In total, only 9 patients (< 1% of all aSAH patients treated at our institution during the study period) had been anticoagulated at admission. Median international normalized ratio (INR) of patients at admission was 2.31 (interquartile range [IQR] 1.83-2.97) and after median administration of 2500 IU (IQR 2000-3000 IU) PCC, median INR significantly decreased to 1.15 (IQR 1.07-1.19). Surgical and interventional procedures were initiated within a median of 3.9 h (IQR 1.7-9.3 h) after admission. No hemorrhagic or thromboembolic events occurred later in the course. A favorable outcome according to the Glasgow Outcome Scale (scores of 4 and 5) was achieved in 6 patients (67%).

Aneurysmal SAH in anticoagulated patients is a rare condition. PCC is an effective option to rapidly reverse anticoagulation in aSAH and might facilitate achieving a favorable outcome in these patients.