Reversal of Antithrombotic Agents in ICH

Antithrombotic Reversal agent
VKA INR ≥ 1.4: Vitamin K 10 mg IV + KCentra OR FFP 10-15 ml/Kg IV if not available
FXa inhibitors 50 g activated charcoal if within 2 + KCentra 50 units/kg IV
DTI Dabigatran reversal:

50 g activated charcoal within 2 h + idarucizumab 5 g IV

HD or repeat idarucizumab for refractory bleeding

Other DTIs: KCentra 50 units/kg IV

UFH Protamine 1 mg IV q 100 U heparin for the past 2–3 h

(up to 50 mg in a single dose)

LMWH Enoxaparin:

Within 8h: Protamine 1 mg IV per 1 mg enoxaparin (up to 50 mg in single dose)

Within 8–12 h: Protamine 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in single dose)

>12 h: minimial utility

Dalteparin, Nadroparin and Tinzaparin:

Within 3–5 half-lives: Protamine 1 mg IV per 100 anti-Xa units (up to 50 mg in single dose)

OR rFVIIa 90 mcg/kg IV if protamine contraindicated

Danaparoid rFVIIa 90 mcg/kg IV
Pentasaccharides Activated PCC (FEIBA) 20 units/kg IV or rFVIIa 90 mcg/kg IV
tPA Cryoprecipitate 10 units IV OR

Antifibrinolytics (TXA 10–15 mg/kg IV over 20 min or aminocaproic acid 4–5 g IV) if cryoprecipitate contraindicated

Antiplatelet agents DDAVP 0.4 mcg/kg IV × 1

If neurosurgical intervention: Platelet transfusion (one apheresis unit)


antithrombotic-agents-in-ich <pdf>

antithrombotic-agents-in-ich <doc>
Warfarin Reversal:


Frontera, Jennifer A. et al. “Guideline For Reversal Of Antithrombotics In Intracranial Hemorrhage”. Neurocritical Care 24.1 (2015): 6-46.

ENLS 2017 Pharmacotherapy.  Neurocritical Care Journal.

Burns, J., Fisher, J. and Cervantes-Arslanian, A. (2018). Recent Advances in the Acute Management of Intracerebral Hemorrhage. Neurosurgery Clinics of North America, 29(2), pp.263-272.

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