Warfarin-related intracerebral hemorrhage: How to proceed

Warfarin-related intracerebral hemorrhage (WICH) is a devastating stroke subtype and represents a medical and neurosurgical emergency with a 1-month mortality of approximately 50%. Warfarin is commonly prescribed to prevent ischemic stroke in patients with atrial fibrillation and to prevent pulmonary embolism (PE) in patients with deep vein thrombosis (DVT). Owing to the aging population and the increased incidence of atrial fibrillation with age and subsequent warfarin use, the incidence of WICH is expected to rise in the future. When WICH occurs, immediate discontinuation of warfarin and simultaneous rapid warfarin-reversal remain the first-line interventions, sometimes with neurosurgical intervention. The optimal agent for the most rapid warfarin anticoagulation reversal remains to be defined owing to the lack of prospective randomized trials. We review current literature about WICH pathogenesis, risk factors, acute management strategies and prospects for future research for this devastating neurologic emergency.