Anticoagulation Reversal & Hemorrhagic Stroke

Stroke

ischemic= thrombotic (atherosclerosis, platelet adherence, arterial stenosis) or embolic (afib, HF, valve disease), clots block blood flow to brain tissue

hemorrhagic stroke= intracerebral (ICH) or subarachnoid (SAH), rupture of blood vessels or aneurysms decrease perfusion/damage tissue/increase pressure, spontaneous (HTN) or traumatic (falls)

Glasgow Coma Scale

neurological assessment tool, includes eye opening, verbal response, motor response

mild=13-15, moderate 9-12, severe 3-8

Oral Anticoagulants

for VTE and stroke prevention, DOACs less bleeding/DDI risk than warfarin

warfarin= vit K antagonist (factor 2, 7, 9, 10), ½ life 1wk, monitor INR/PT

dabigatran= direct thrombin inhibitor, ½ life 12-17hrs, can check PT/aPTT

xabans= direct factor Xa inhibitor, ½ life apix 12hrs, edox 10-14hrs, rivarox 5-9hrs, can check PT/specific anti-Xa assay

Reversal Strategies (only needed within 5 ½ lives)

consider site/severity, mechanical (HD for renally eliminated not protein bound dabiagtran) or pharmacologic (topical agents, activated charcoal if within few hours, antidotes, promoting hemostasis)

promote hemostasis= vitamin K (5-10mg 1mg/min IV faster onset than PO), fresh-frozen plasma (all clotting factors), PCCs (3=factors 2,9,10, 4=2,7,9,10, activated=7) less volume

antidotes= idarucizumab (binds dabigatran, 5g IV as 2×2.5g doses 15mins apart), andexanet alfa (removed due to thrombotic events)

use antidotes if available then PCC (don’t give VK alone)

Monitoring

repeat CT 6hrs (assess hematoma expansion), GCS (neurologic status), SBP<140 (prevent hematoma expansion), thrombosis risk (stroke, DVT/PE), flushing/anaphylaxis for IV agents, INR with warfarin (<1.5=reversal, if not goal give more PCC since onset within 30 mins while VK is more like 24hrs)