ffp versus pcc in intracranial hemorrhage

Conditions: Intracranial Hemorrhage, Traumatic; Intracranial Hemorrhage, Spontaneous

Summary: the goal of this study will be to determine whether pcc confers any benefits over ffp in traumatic and spontaneous intracranial hemorrhage with respect to multiple factors including time to correction, absolute international normalized ratio correction amount, cost, need for surgical intervention, and radiographic bleed expansion through a prospective, randomized control trial.

vitamin k antagonists in general and coumadin in particular remains the most common form of outpatient anticoagulation in patients today. despite the therapeutic benefits of these agents, bleeding in general and intracranial bleeding in particular are significant risks associated with these medications. intracranial bleeding on oral anticoagulation agents are associated with a 20% increase in 30 day mortality versus non-anticoagulated controls, and rapid reversal of vitamin k antagonists in this population has been shown to have survival benefits. historically, vitamin k antagonists have been reversed using fresh frozen plasma (ffp) transfusions which, though effective, often incur delays due to the time required to obtain a type \& screen, thaw the product, and administer the product to the patient. in 2013, the fda approved 4-factor prothrombin complex (pcc), a concentrate of factors ii, vii, ix, x, protein c and protein s for use as a method for correcting vitamin k antagonist related coagulopathy. though large, prospective randomized control trials have demonstrated efficacy and safety in a general population of all-comers bleeding, there is very little literature regarding the benefits of pcc versus ffp in the traumatic and spontaneous intracranial hemorrhage population. current standard of care in patients with traumatic and spontaneous intracranial hemorrhage who are on vitamin k antagonists is to reverse the effect of these agents with ffp or pcc. the choice of which agent to use is currently determined by both availability of each agent and surgeon preference. for this study, there will be an equal likelihood of either treatment being given. the goal of this study will be to determine whether pcc confers any benefits over ffp in traumatic and spontaneous intracranial hemorrhage with respect to multiple factors including time to correction, absolute international normalized ratio correction amount, cost, need for surgical intervention, and radiographic bleed expansion through a prospective, randomized control trial.

Eligibility criteria:
inclusion criteria: * coumadin use * inr of 2.0 or higher on arrival at the study center * evidence on cranial imaging of spontaneous intracranial hemorrhage, subdural hematoma, epidural hematoma, cerebral contusion, traumatic subarachnoid hemorrhage, or traumatic intraparenchymal hemorrhage exclusion criteria: * unable to obtain consent * estimated survival \<24 hours * hypersensitivity to 4 factor prothrombin complex concentrate * concomitant use of novel vitamin k antagonists * religious/social prohibition to receiving blood products * need for emergent, non-neurosurgical operative intervention * mechanical heart valves

Keywords: warfarin traumatic intracranial hemorrhage prothrombin complex concentrate fresh frozen plasma spontaneous intracranial hemorrhage