Reversing Anticoagulants in Intracerebral Hemorrhage Clinical Practice Guidelines (2020)

European Stroke Organisation

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 03, 2020

In December 2019, the European Stroke Organisation (ESO) released their recommendations on the reversal of oral anticoagulants in acute intracerebral hemorrhage (ICH).[1] Oral anticoagulants include vitamin K antagonists (VKAs) (warfarin, phenprocoumon, and acenocoumarol), direct factor II (thrombin) inhibitors (dabigatran etexilate), and factor-Xa (fXa)-inhibitors (apixaban, edoxaban, and rivaroxaban).

Strong Recommendations

Use prothrombin complex concentrate (PCC) (30 IU/kg) for ICH occurring during the use of VKAs (international normalized ratio [INR] above normal):

  • Over no treatment, to reduce mortality and normalize INR in adults

  • Over FFP (20 mL/kg), to reduce mortality and normalize INR in patients

In adults with ICH occurring during the use of VKAs (INR above normal), use vitamin K (10 mg intravenously [IV]) in addition to fast reversal strategies including PCC to prevent re-increase of INR to decrease hematoma expansion and reduce mortality. ESO recommends against the use of tranexamic acid in this setting.

In patients with ICH occurring during the use of VKAs, ESO recommends against using recombinant factor VIIa (rFVIIa) to improve outcome, decrease hematoma expansion, or increase normalization of INR.

In adults with ICH occurring during the use of dabigatran, idarucizumab is recommended to reverse the effects of dabigatran.

ESO recommends against the administration of ciraparantag outside of clinical trials.

Weak Recommendations

In patients with ICH occurring during the use of non-vitamin K antagonist oral anticoagulation (NOAC) (fXa inhibitors), consider using 4-factor PCC (37.5–50 IU/kg) to reverse the anticoagulant effect.

In patients with ICH occurring during the use of NOAC, ESO recommends against using FFP to improve outcome, reduce mortality, decrease hematoma expansion, or reverse the effects of NOAC.

In adult patients with ICH occurring during the use of rivaroxaban or apixaban, andexanet alfa may be considered to reverse the anticoagulant effect.

For more Clinical Practice Guidelines, please go to Guidelines.

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