A 58-year-old man with uncontrolled hypertension presents with sudden-onset severe headache, vomiting, and left-sided hemiparesis. CT head shows a right basal ganglia hemorrhage with intraventricular extension. Regarding the management and prognostic factors in intracerebral hemorrhage (ICH), all of the following are true EXCEPT:

Explanation

## Anticoagulation Reversal in Warfarin-Associated ICH **Key Point:** Prothrombin complex concentrate (PCC) is now the standard of care for rapid reversal of warfarin in ICH, NOT fresh frozen plasma (FFP). Therefore, Option B is FALSE — making it the correct "EXCEPT" answer. ### Why PCC is Superior to FFP | Feature | PCC | FFP | |---------|-----|-----| | **Onset of action** | 15–30 minutes | 4–6 hours | | **Volume required** | 25–50 mL/kg | 10–15 mL/kg | | **INR correction** | Rapid, reliable | Slower, variable | | **Fluid overload risk** | Low | High | | **Current guideline recommendation** | First-line | Avoid if PCC available | **High-Yield:** The 2015 AHA/ASA guidelines and subsequent updates strongly recommend PCC (25–50 units/kg IV) over FFP for warfarin reversal in ICH because it achieves faster INR normalization without volume overload. ### Analysis of All Options **Option A — TRUE (rFVIIa):** - The FAST trial demonstrated that recombinant factor VIIa, when given within 4 hours of ICH onset, significantly limits hematoma expansion (~25% reduction) - However, it does NOT improve functional outcomes or mortality, limiting its routine clinical use - Statement as written is factually correct regarding hematoma expansion benefit **Option B — FALSE (correct EXCEPT answer):** - FFP is NOT superior to PCC for warfarin reversal in ICH - PCC is faster, more reliable, and carries lower risk of volume overload - This statement is the exception — it is incorrect **Option C — TRUE (ICH Score):** The ICH Score components are: - GCS score (0–2 points) - ICH volume ≥30 mL (1 point) - Intraventricular hemorrhage presence (1 point) - Infratentorial origin (1 point) - Age ≥80 years (1 point) - Predicts 30-day mortality; score 0 = ~0% mortality, score 5–6 = ~100% mortality > **Note:** The stem's description of ICH Score components is slightly simplified but directionally correct for exam purposes. **Option D — TRUE (BP target in acute ICH):** - In acute ICH, the recommended target is SBP **<140 mmHg** (INTERACT2 trial), which represents *aggressive* blood pressure lowering — not "permissive hypertension" in the traditional sense - The term "permissive hypertension" in Option D is a misnomer (permissive hypertension means *allowing* higher BP, as in ischemic stroke), but the stated target of SBP <140 mmHg is the correct guideline-recommended goal for ICH - The option is internally inconsistent in terminology but the SBP target cited (<140 mmHg) is correct per AHA/ASA guidelines, making the overall statement TRUE for exam purposes ## Clinical Pearl **Warning:** FFP is no longer recommended as first-line reversal in warfarin-associated ICH due to delayed onset and volume overload risk. Always use PCC if available. Do not confuse "permissive hypertension" (used in ischemic stroke/TBI) with the aggressive BP control target of SBP <140 mmHg recommended in hemorrhagic stroke. [cite: Harrison 21e Ch 297; AHA/ASA Guidelines for Management of Spontaneous ICH 2022]