Stroke Prenotification Is Associated with Shorter Treatment Times for Warfarin-Associated Intracerebral Hemorrhage

Background: Warfarin-associated intracerebral hemorrhage (WAICH) is a devastating disease with increasing incidence. In this setting, treatment with prothrombin complex concentrates (PCC) is essential to correct coagulopathy. Yet despite the availability of coagulopathy correction strategies, significant treatment delays can occur in emergency departments (EDs), which may be overcome using stroke prenotification strategies. To explore this, we compared arrival-to-treatment times with PCC for WAICH between two different stroke response systems that used the same international normalized ratio (INR) correction protocol. Methods: We established a registry of consecutive patients presenting with WAICH and treated with PCC presenting to two Canadian tertiary-care academic stroke centers: one with a stroke prenotification system, and one with a traditional ED assessment, treatment and referral system. In this comparative cohort design, we defined the WAICH diagnosis time as the earliest time point where both INR and CT were available. We compared median times from arrival to treatment, as well as arrival to diagnosis, and diagnosis to treatment. Results: Between 2008 and 2010, we collected data from 123 consecutive patients with intracranial hemorrhage who received PCC for INR correction (79 from ED referral, and 44 prenotification). Onset-to-arrival times, demographics, Glasgow Coma Scale scores, and baseline INR were similar between the two systems. Arrival-to-treatment times were significantly shorter in the prenotification system as compared to the traditional ED referral system (135 vs. 267 min; p = 0.001), which was driven by both decreased arrival-to-diagnosis time (49 vs. 117 min; p = 0.006), as well as decreased diagnosis-to-treatment time (56 vs. 112 min; p < 0.001). Arrival-to-scan times and arrival-to-INR times were similarly shorter in the prenotification system (68 vs. 118 min and 20.5 vs. 47 min, respectively). Conclusion: Stroke prenotification was associated with shorter arrival-to-treatment times for emergent INR correction in patients with WAICH, which was driven by both faster diagnosis and treatment. Our results are consistent with those seen in ischemic stroke, suggesting that prenotification systems present an opportunity to optimize acute intracerebral hemorrhage therapy.

[1]  A. Demchuk,et al.  The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial , 2013, Stroke.

[2]  J. Coquart,et al.  Emergency reversal of anticoagulation: the real use of prothrombin complex concentrates: a prospective multicenter two year French study from 2006 to 2008. , 2012, Thrombosis research.

[3]  S. Prabhakaran,et al.  Warfarin-Associated Intracerebral Hemorrhage Is Inadequately Treated at Community Emergency Departments , 2012, Stroke.

[4]  Atte Meretoja,et al.  Reducing in-hospital delay to 20 minutes in stroke thrombolysis , 2012, Neurology.

[5]  K. Butcher,et al.  Poor Prognosis in Warfarin-Associated Intracranial Hemorrhage Despite Anticoagulation Reversal , 2012, Stroke.

[6]  S. Whyte,et al.  FASTER (Face, Arm, Speech, Time, Emergency Response): Experience of Central Coast Stroke Services implementation of a pre-hospital notification system for expedient management of acute stroke , 2012, Journal of Clinical Neuroscience.

[7]  D. Krieger,et al.  European Research Priorities for Intracerebral Haemorrhage , 2011, Cerebrovascular Diseases.

[8]  Y. Palesch,et al.  Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) II: Design, Methods, and Rationale , 2011, Neurocritical care.

[9]  M. Hennerici,et al.  International Normalised Ratio Normalisation in Patients with Coumarin-Related Intracranial Haemorrhages – the INCH Trial: A Randomised Controlled Multicentre Trial to Compare Safety and Preliminary Efficacy of Fresh Frozen Plasma and Prothrombin Complex – Study Design and Protocol , 2011, International journal of stroke : official journal of the International Stroke Society.

[10]  H. Naritomi,et al.  Effect of Prothrombin Complex Concentrate on Hematoma Enlargement and Clinical Outcome in Patients with Anticoagulant-Associated Intracerebral Hemorrhage , 2010, Cerebrovascular Diseases.

[11]  C. Anderson,et al.  Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2010, Stroke.

[12]  A. Demchuk,et al.  The Intracerebral Haemorrhage Acutely Decreasing Arterial Pressure Trial: ICH ADAPT , 2010, International journal of stroke : official journal of the International Stroke Society.

[13]  Gregory W Albers,et al.  Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials , 2010, The Lancet.

[14]  L. Morrison,et al.  A Citywide Prehospital Protocol Increases Access to Stroke Thrombolysis in Toronto , 2009, Stroke.

[15]  S. Kasner,et al.  Hematoma Growth in Oral Anticoagulant Related Intracerebral Hemorrhage , 2008, Stroke.

[16]  J. Broderick,et al.  Warfarin use leads to larger intracerebral hematomas , 2008, Neurology.

[17]  J. Broderick,et al.  The increasing incidence of anticoagulant-associated intracerebral hemorrhage , 2007, Neurology.

[18]  H. Riess,et al.  Prothrombin complex concentrate (Octaplex) in patients requiring immediate reversal of oral anticoagulation. , 2007, Thrombosis research.

[19]  Stephen S. Cha,et al.  Secular Trends in Incidence of Atrial Fibrillation in Olmsted County, Minnesota, 1980 to 2000, and Implications on the Projections for Future Prevalence , 2006, Circulation.

[20]  T. Steiner,et al.  Intracerebral Hemorrhage Associated With Oral Anticoagulant Therapy: Current Practices and Unresolved Questions , 2006, Stroke.

[21]  R. Zimlichman,,et al.  Efficacy and safety of a prothrombin complex concentrate (Octaplex) for rapid reversal of oral anticoagulation. , 2004, Thrombosis research.