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Warfarin-associated cerebellar intracerebral haemorrhage — MRCEM SBA MCQ

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HardNeurological emergenciesWarfarin-associated cerebellar intracerebral haemorrhageMRCEM SBA

A 62-year-old woman taking warfarin for a mechanical aortic valve presents two hours after abrupt onset of headache, vomiting and inability to walk. Her Glasgow Coma Scale score is 14, her airway is maintained, her systolic blood pressure is 184 mmHg and her INR is 2.8. CT shows a spontaneous cerebellar haemorrhage effacing the fourth ventricle. A regional neurosurgeon has accepted her for immediate haematoma evacuation. Prothrombin complex concentrate is available in the emergency department. Which plan is most appropriate before transfer?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Give prothrombin complex concentrate and intravenous vitamin K; defer rapid blood pressure lowering; transfer urgently.

This is a primary intracerebral haemorrhage in a patient taking warfarin with an elevated INR. NICE recommends correcting clotting as soon as possible with **both** prothrombin complex concentrate and intravenous vitamin K. The mechanical valve is an important indication for her usual anticoagulation, but does not change the immediate reversal decision during this bleed. Reversal should be started while urgent transfer to the accepting neurosurgical centre is arranged. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations)) B is tempting: presentation is within six hours and systolic pressure lies in the range for which rapid lowering would ordinarily be considered. However, NICE specifically excludes patients proceeding to early haematoma evacuation. This does not mean ignoring blood pressure; it should be monitored and managed in discussion with the receiving team. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations)) C omits the concentrate needed for prompt correction. D omits intravenous vitamin K from the recommended combined regimen. E substitutes plasma despite the availability of the recommended concentrate. Each alternative retains urgent transfer but makes a consequential error in treatment before departure. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations))

Reference: NICE NG128, recommendation 1.4.16: reversal of anticoagulation in haemorrhagic stroke (2008; amended 2019) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations NICE NG128, recommendations 1.5.4 and 1.5.7: blood pressure control in acute intracerebral haemorrhage (Recommendations 1.5.4 updated 2022; 1.5.7 published 2019) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations NICE NG128, recommendation 1.9.1: neurosurgical referral and transfer in acute intracerebral haemorrhage (2008) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations