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Clinical Question

How do I reverse anticoagulation in ICH?

Synthesises 4 trialsFXa, dabigatran, warfarin, and antiplatelet ICH. Each requires a different reversal strategy

Clinical Synthesis

In anticoagulant-associated ICH, give 4F-PCC plus IV vitamin K for VKA reversal, idarucizumab for dabigatran, and 4F-PCC for factor Xa inhibitors (andexanet alfa was withdrawn from the US market on December 22, 2025 after FDA concluded its risks outweighed its benefits); do NOT transfuse platelets for antiplatelet-associated ICH outside of a planned neurosurgical procedure.

Bottom line

Reverse by agent: 4F-PCC 25 to 50 U/kg + IV vitamin K for warfarin, idarucizumab 5 g IV for dabigatran, 4F-PCC 50 U/kg for factor Xa inhibitors (andexanet alfa unavailable in the US after December 22, 2025 per FDA risk-benefit conclusion and AstraZeneca voluntary withdrawal). Do NOT transfuse platelets for antiplatelet-associated ICH unless the patient is heading to neurosurgery (PATCH showed harm; AHA/ASA Class III).

Sources

Andexanet for Factor Xa Inhibitor-Associated Acute Intracerebral Hemorrhage· 2024Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors· 2019Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding· 2013Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH)· 2016§7.3 Hemostatic Therapies· 2022Risk-benefit conclusion· 2024Andexxa· 2025

Trials in this question· 4

Sarode 20132013
4F-PCC noninferior to FFP on hemostasis, superior on rapid INR reduction; FDA approval of Kcentra.
Non-inferior+7.1 pp (-5.8 to +19.9)
PATCH2016
Platelet transfusion in antiplatelet-associated ICH worsens 3-month outcome; AHA/ASA 2022 Class III Harm.
HarmaOR 2.05 (1.18-3.56)
ANNEXA-42019
Single-arm cohort: andexanet reduced anti-FXa by 92% with 82% hemostatic efficacy in FXa-inhibitor major bleeding.
FDA approval cohort82% hemostasis at 12 h
ANNEXA-I2024
Andexanet improves hemostatic surrogate but increases ischemic stroke; no functional or mortality benefit at 30 days.
NNT 8 / NNH 20+13.4 pp (4.6-22.2)

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