Fast Five Quiz: Test Your Knowledge on Key Aspects of Hemorrhagic Stroke

Amy Kao, MD


May 10, 2018

The need to reverse warfarin anticoagulation is a true medical emergency, and reversal must be accomplished as quickly as possible to prevent further hematoma expansion. Options for reversal therapy include the following:

  • Intravenous vitamin K

  • Fresh frozen plasma

  • Prothrombin complex concentrates

  • rFVIIa

Because vitamin K requires more than 6 hours to normalize the international normalized ratio, it should be administered with either fresh frozen plasma or prothrombin complex concentrates. Fresh frozen plasma is the standard of care in the United States; however, fresh frozen plasma needs to be given in a dose of 15-20 mL/kg and therefore requires a large-volume infusion.

No effective targeted therapy for hemorrhagic stroke is available. Studies of rFVIIa have yielded disappointing results. Evacuation of hematoma, either via open craniotomy or endoscopy, may be a promising ultra-early-stage treatment for intracerebral hemorrhage that may improve long-term prognosis.

The use of prophylactic anticonvulsant medication remains uncertain. In prospective and population-based studies, clinical seizures have not been associated with worse neurologic outcome or mortality. Indeed, two studies have reported worse outcomes in patients who did not have a documented seizure but who received antiepileptic drugs (primarily phenytoin).

No controlled studies have defined optimum blood pressure levels for patients with acute hemorrhagic stroke, but greatly elevated blood pressure is thought to lead to rebleeding and hematoma expansion. Stroke may result in loss of cerebral autoregulation of cerebral perfusion pressure. Intensive blood pressure reduction (target blood pressure <140 mm Hg systolic) early in the treatment of patients with intracerebral hemorrhage appears to lessen the absolute growth of hematomas, particularly in patients who have received previous antithrombotic therapy, according to a combined analysis of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials 1 and 2 (INTERACT).

For more on the treatment of hemorrhagic stroke, read here.


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