Recombinant factor VIIa for rapid reversal of anticoagulant effect in patients with intracranial hemorrhage: the Israeli experience and review of the literature.

Spontaneous intracerebral hemorrhage accounts for 4–5% of cases of acute stroke and is associated with a substantially worse prognosis than ischemic stroke. Spontaneous intracerebral hemorrhage is associated with a high mortality rate, almost 50%. Intracranial hemorrhages associated with oral anticoagulants can be divided into intracerebral, subdural/epidural, and subarachnoid. ICH constitutes approximately 70% of oral anticoagulant-associated intracranial hemorrhages, while subdural hematomas comprise the majority of the remainder. Subarachnoid hemorrhage is a rare complication. Both ICH and subdural hematoma can occur simultaneously in anticoagulated patients. Although infrequent, the incidence of oral anticoagulant-related intracerebral hemorrhage (OAC-ICH) is seven-to tenfold higher than in patients not taking OAC, with a mortality rate of approximately 60%. OAC-related subdural hematomas are less frequently reported than ICH and the risk is increased four-to 15-fold in patients on OAC. In about half of these anticoagulated patients with ICH the bleeding evolves slowly over 12 to 24 hours, and emergency reversal of anticoagulation is crucial. Despite accumulating knowledge, our understanding of OAC-ICH remains limited and there are currently no universally accepted guidelines for treatment. This paper briefly reviews the epidemiology, pathophysiology and current treatment options for OAC-related intracranial hemorrhage , including the Israeli experience. Epidemiology In epidemiologic studies the incidence of all strokes ranges from 200 to 500 per 100,000, and ICH accounts for 8–15% of strokes [1]. The worldwide incidence of spontaneous intracerebral hemorrhage ranges from 10 to 20 per 100,000 population/year [2], and increases with age, doubling every 10 years after age 35 [3]. Spontaneous intracerebral hemorrhage is more common in men than women, particularly those older than 55 [2,4]. The rate of occurrence is highest in Asians, intermediate in blacks, and lowest in whites, with an incidence in blacks almost twice that ICH = intracerebral hemorrhage OAC = oral anticoagulant among whites [5,6]. The incidence of intracerebral hemorrhage in the Japanese population is similar to that among blacks [7]. The absolute rate of OAC-related intracerebral hemorrhage (OAC-ICH) is difficult to predict accurately; the reported incidence is seven-to tenfold higher than in patients not treated by OAC [8-11]. According to reported studies, OAC-ICH accounts for 10–12% of all ICH [12]. Thus, the estimated OAC-ICH occurs at a rate 2 to 9/100,000 population per year [13]. OAC are administered to treat or prevent primary and secondary venous and arterial throm-boembolic complications. Atrial fibrillation, a common condition in the elderly, represents the most common long-term indication. As the number of …