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Warfarin therapy and predilection for infratentorial hemorrhage
Journal of the Neurological Sciences 337 (2014) 239
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Response to Letter to the Editor Warfarin therapy and predilection for infratentorial hemorrhage
Dear Editor: We read with interest the letter from Dr. Ding regarding our article in which we showed that warfarin-related intracerebral hemorrhage (ICH) demonstrated a predilection for brainstem location. We further showed that previous treatment with warfarin together with INR more than 3.0 was an independent predictor of infratentorial hemorrhage. In our study, there were 17 patients on warfarin with infratentorial ICHs. Among these patients, 10 had brainstem ICH and 7 had cerebellum ICH. The proportion of infratentorial ICH was 24.6% (17/69) in warfarin group and 15.8% (53/335) in non-warfarin group. Although our results showed an association between anticoagulation and infratentorial hemorrhage, we agreed with Dr. Ding that the small number of warfarin patients in our study imposed limited power to confirm with certainty the association of warfarin-associated ICH with infratentorial location. Dr. Ding stated that warfarin-related cerebellar ICH patients were more likely to be transferred from other hospitals to our institution for surgical intervention, leading to a higher proportion of warfarinassociated infratentorial ICH in our study. We would like to point out that there were only 7 warfarin-related ICH patients transferred from other hospitals in our data set. Of those 7 warfarin-related ICH patients, 4 had supratentorial hemorrhage, 2 had cerebellar ICH and 1 had brainstem ICH. Two patients with lobar hemorrhages underwent surgical intervention. There was no referral bias which may have increased the proportion of warfarin-associated infratentorial ICHs in our study. Patients with cerebellar ICH who develop neurological deterioration or brainstem compression and/or hydrocephalus from ventricular obstruction are recommended to be treated by neurosurgical intervention [1]. The American Heart Association and American Stroke Association guidelines further recommend rapid reversal of systemic anticoagulation by infusions of vitamin K, fresh frozen plasma, or prothrombin complex concentrates and Factor VIIa for patients presented with oral anticoagulant-related ICH [1]. Rapid reversal of anticoagulation is available in most institutions. Early reversal of international normalized ratio enables
0022-510X/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jns.2013.11.010
emergent surgical evacuations in warfarin-related ICH patients who rapidly deteriorate. A higher incidence of favorable functional recovery has been reported in warfarin-related ICH patients who underwent urgent surgical evacuation after reversal of anticoagulation despite the presence of clinical deterioration [2]. Therefore, anticoagulation-related ICH may not influence surgical and referral decision-making. In conclusion, we agreed with Dr. Ding that our study had a small number of warfarin-related ICH patients, especially in the group with higher INR. Given that the underlying mechanism by which anticoagulant worsens ICH recovery has not been fully investigated, further research is needed for a better understanding of the determinants of outcome in anticoagulation-related ICH. Conflict of interest The authors report no conflicts of interest. References [1] Morgenstern LB, Hemphill III JC, Anderson C, Becker K, Broderick JP, Connolly Jr ES, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2010;41:2108–29. [2] Rabinstein AA, Wijdicks EF. Determinants of outcome in anticoagulation-associated cerebral hematoma requiring emergency evacuation. Arch Neurol 2007;64:203–6.
Minmin Ma Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Australia Bernard Yan Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Australia Department of Medicine, University of Melbourne, Melbourne, Australia Corresponding author at: Melbourne Brain Centre, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia. Tel.: +61 3 9349 2477; fax: +61 3 9342 8427. E-mail address: [email protected]
3 November 2013
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Response to Letter to the Editor Warfarin therapy and predilection for infratentorial hemorrhage
Dear Editor: We read with interest the letter from Dr. Ding regarding our article in which we showed that warfarin-related intracerebral hemorrhage (ICH) demonstrated a predilection for brainstem location. We further showed that previous treatment with warfarin together with INR more than 3.0 was an independent predictor of infratentorial hemorrhage. In our study, there were 17 patients on warfarin with infratentorial ICHs. Among these patients, 10 had brainstem ICH and 7 had cerebellum ICH. The proportion of infratentorial ICH was 24.6% (17/69) in warfarin group and 15.8% (53/335) in non-warfarin group. Although our results showed an association between anticoagulation and infratentorial hemorrhage, we agreed with Dr. Ding that the small number of warfarin patients in our study imposed limited power to confirm with certainty the association of warfarin-associated ICH with infratentorial location. Dr. Ding stated that warfarin-related cerebellar ICH patients were more likely to be transferred from other hospitals to our institution for surgical intervention, leading to a higher proportion of warfarinassociated infratentorial ICH in our study. We would like to point out that there were only 7 warfarin-related ICH patients transferred from other hospitals in our data set. Of those 7 warfarin-related ICH patients, 4 had supratentorial hemorrhage, 2 had cerebellar ICH and 1 had brainstem ICH. Two patients with lobar hemorrhages underwent surgical intervention. There was no referral bias which may have increased the proportion of warfarin-associated infratentorial ICHs in our study. Patients with cerebellar ICH who develop neurological deterioration or brainstem compression and/or hydrocephalus from ventricular obstruction are recommended to be treated by neurosurgical intervention [1]. The American Heart Association and American Stroke Association guidelines further recommend rapid reversal of systemic anticoagulation by infusions of vitamin K, fresh frozen plasma, or prothrombin complex concentrates and Factor VIIa for patients presented with oral anticoagulant-related ICH [1]. Rapid reversal of anticoagulation is available in most institutions. Early reversal of international normalized ratio enables
0022-510X/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jns.2013.11.010
emergent surgical evacuations in warfarin-related ICH patients who rapidly deteriorate. A higher incidence of favorable functional recovery has been reported in warfarin-related ICH patients who underwent urgent surgical evacuation after reversal of anticoagulation despite the presence of clinical deterioration [2]. Therefore, anticoagulation-related ICH may not influence surgical and referral decision-making. In conclusion, we agreed with Dr. Ding that our study had a small number of warfarin-related ICH patients, especially in the group with higher INR. Given that the underlying mechanism by which anticoagulant worsens ICH recovery has not been fully investigated, further research is needed for a better understanding of the determinants of outcome in anticoagulation-related ICH. Conflict of interest The authors report no conflicts of interest. References [1] Morgenstern LB, Hemphill III JC, Anderson C, Becker K, Broderick JP, Connolly Jr ES, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke 2010;41:2108–29. [2] Rabinstein AA, Wijdicks EF. Determinants of outcome in anticoagulation-associated cerebral hematoma requiring emergency evacuation. Arch Neurol 2007;64:203–6.
Minmin Ma Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, PR China Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Australia Bernard Yan Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, Australia Department of Medicine, University of Melbourne, Melbourne, Australia Corresponding author at: Melbourne Brain Centre, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia. Tel.: +61 3 9349 2477; fax: +61 3 9342 8427. E-mail address: [email protected]
3 November 2013