経口的抗凝固療法中の頭蓋内出血の治療

Abstract

We evaluated 5 patients with intracranial hemorrhage associated with oral anticoagulant therapy (OACT) over a 15-month period. All patients were taking warfarin. They had a mean age of 69 years (age range, 61 to 78). One patient had suffered from spontaneous thalamic hemorrhage while walking. Each of the other 4 patients had a history of minor head trauma. Three patients' symptoms had progressed slowly and were diagnosed as intracranial hemorrhage more than 12 hours after head trauma. Four patients had intracerebral hematoma and 3 had acute subdural hematoma. Two had both. One had hematomas in both the supra- and infratentorial space. All patients had been on OACT for less than 5 years. Three of the patients were taking OACT for peripheral vascular disease, (2 of whom received arterial grafts), and 2 who were suffering from cardiac valve disease received bioprosthetic valves. Two patients underwent prosthetic surgery within less than a week, and started OACT only 3 and 4 days, respectively, before having intracranial hemorrhage. Two received bucolome, 2 received antiplatelet drugs and 1 received heparin to support warfarin. Two patients were alcohol abusers. All of their international normalized ratios (INRs) of prothrombin time were higher than 1.5, and 3 of them were higher than 3.0 (mean 3.7). Surgical treatment was selected for 3 patients who showed consciousness disturbance. Vitamin K2 only, was used for warfarin reversal in the 3 early cases. Fresh frozen plasma (FFP) only was used for 1 patient and both were used for the other 1. Treatment with vitamin K2 needs more than 24 hours to reverse the effects of warfarin completely. FFP needs less than 6 hours. FFP is more effective for emergency operations. In the surgical cases, hemorrhage was difficult to stanch while the INR was higher than 2.0, and it was easy when the INR was lower than 1.3. One patient had rebleeding 5 hours after diagnosis of thalamic hemorrhage and died on the same day. Only 1 patient's prognosis was good 3 months after the onset of the hemorrhage. He restarted warfarin 6 days after the diagnosis of intracranial hemorrhage.