Prothrombin complex concentrate administration timing in warfarin-associated intracranial hemorrhage

INTRODUCTION

Guidelines recommend "rapid" and "urgent" reversal of anticoagulation for warfarin-associated intracranial hemorrhage (ICH) treatment; however, they do not specify goals for time-to-administration. There are limited studies evaluating time to reversal, or international normalized ratio (INR) correction, on hematoma expansion and outcomes in intervals of <4 h. The purpose of this study was to evaluate the association of 4-factor prothrombin concentrate (4F-PCC) time-to-administration on rates of achieving effective hemostasis, determined by hematoma expansion, for treatment of warfarin-associated ICH.

METHODS

This was a retrospective, observational, single center study performed at a large community teaching hospital. Patients were stratified into three groups based on time of CT diagnosis of ICH to administration of 4F-PCC: <45 min, 45-90 min, and >90 min. The primary outcome was rates of achieving effective hemostasis in each group defined as a ≤20% increase in hematoma volume as estimated by a radiologist.

RESULTS

A total of 227 patients were screened for inclusion with ultimately 39 being included. Baseline characteristics were similar between groups. The primary outcome was not significantly different among groups stratified by time to 4F-PCC administration of <45 min, 45-90 min, and >90 min (85.7% vs 73.3% vs 90%, p value 0.514). There was no difference among secondary outcomes between groups including in-hospital mortality, hospital length of stay (LOS), and intensive care unit LOS.

CONCLUSION

There was no association with time-to-administration of 4F-PCC on rates of hemostasis achievement, defined as hematoma expansion of ≤20%, identified in this study.

A Case of Ivermectin-Induced Warfarin Toxicity: First Published Report

Here, we present the case of a patient who developed a large hematoma under his tongue while taking concomitant warfarin and ivermectin. Ivermectin has been shown to interfere with vitamin K-dependent clotting factors II, V, VII, and X. However, all the data to date have been from in vivo data with little to no reports on its effects on humans. To our knowledge, this is the first case report to present such a case.

[Personal experience with the Milwaukee orthosis in the treatment of idiopathic scoliosis]

The authors evaluate the results of treatment of idiopathic scoliosis by a Milwaukee brace in 192 patients with treatment initiated and terminated in 1975 to 1985. In the group of 116 juvenile scolioses at the end of the investigation 26 had improved, 53 did not improve and 37 deteriorated. In the group of adolescent scoliosis 18 improved, 44 did not improve and 11 deteriorated. In the group of improved patients the number of persons declines with the time interval after completed treatment. With the increasing severity of the initial curve the effect of treatment by a brace diminishes. The percentage of non-cooperating patients is substantially higher in the group of not improved and deteriorated cases. In 26 selected patients the authors investigated the lordosis-promoting effect of the brace on the thoracic spine. Because of progression of the deformity the authors operated 12 patients with juvenile and one patients with adolescent scoliosis.