Warfarin-associated primary intracerebral haemorrhage — MRCEM SBA MCQ

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EasyNeurological emergenciesWarfarin-associated primary intracerebral haemorrhageMRCEM SBA

A 69-year-old woman presents 45 minutes after sudden dysarthria and right arm weakness. She takes warfarin for atrial fibrillation. She is alert, has no history of head injury, and her capillary glucose is 6.1 mmol/L. CT head shows an acute left putaminal haemorrhage; her INR is 3.0. The stroke team has been contacted. Which is the most appropriate immediate treatment to reverse her anticoagulation?

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Correct answer: B — Withhold warfarin and give prothrombin complex concentrate with intravenous vitamin K.

The focal deficit requires an acute stroke pathway, but CT establishes that this is an intracerebral haemorrhage rather than an ischaemic stroke. Her warfarin use and elevated INR make anticoagulation reversal time-critical. NICE recommends returning clotting levels to normal as soon as possible with prothrombin complex concentrate (PCC) **and intravenous vitamin K**. PCC supplies rapid factor replacement; vitamin K helps sustain reversal. The INR should then be checked to confirm adequate reversal, alongside continued neurological monitoring and specialist stroke care. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/chapter/Recommendations)) A includes the necessary vitamin K but omits rapid factor replacement. C also replaces clotting factors, but fresh frozen plasma is less suitable than the recommended PCC for prompt reversal. D provides PCC but omits vitamin K, so its effect may not be sustained. E is an emergency reversal agent for dabigatran, not warfarin. Although an INR of 3.0 may be acceptable for some anticoagulation indications, it is elevated in the context of this intracerebral haemorrhage and does not justify delaying reversal. ([nice.org.uk](https://www.nice.org.uk/guidance/ng128/evidence/full-guideline-pdf-6777400862))

Reference: NICE NG128, recommendation 1.4.16: reversal of anticoagulation in haemorrhagic stroke (Recommendation amended 2019) — https://www.nice.org.uk/guidance/ng128/chapter/Recommendations NICE NG24, Blood transfusion, recommendations 1.12.3 and 1.12.6 (Recommendations 2015; guideline updated 26 February 2026) — https://www.nice.org.uk/guidance/ng24/resources/blood-transfusion-pdf-1837331897029 NICE NG128, full guideline: anticoagulation reversal in primary intracerebral haemorrhage (2019) — https://www.nice.org.uk/guidance/ng128/evidence/full-guideline-pdf-6777400862