Kelsey N Sauers, Paris L Tomlinson, Talyr E Hall
Warfarin remains the anticoagulant of choice for patients with mechanical heart valves because of its effectiveness in preventing thromboembolic events. However, management becomes particularly challenging when severe supratherapeutic anticoagulation is complicated by intracranial hemorrhage. We present the case of a 76-year-old male patient with a mechanical mitral valve on chronic warfarin therapy who presented after a ground-level fall with head trauma and an admission international normalized ratio (INR) of 9.0. Initial computed tomography (CT) of the head demonstrated only a scalp hematoma without intracranial hemorrhage, with the patient being neurologically intact. Approximately 12 hours later, worsening headache prompted repeat CT imaging, which revealed a new subarachnoid hemorrhage with intraventricular extension and an INR of 10.2 despite withholding warfarin since admission. Anticoagulation was promptly reversed with intravenous vitamin K and prothrombin complex concentrate (PCC), and serial imaging demonstrated a stable hemorrhage without the need for neurosurgical intervention. PCC was selected over fresh frozen plasma as it provides more rapid INR correction with a substantially lower infusion volume. Given the patient's high thromboembolic risk from a mechanical mitral valve, anticoagulation was cautiously resumed with heparin bridging followed by warfarin after hemorrhage stabilization. Recent ciprofloxacin exposure, acute alcohol intoxication, and marijuana use were identified as potential contributors to the markedly elevated INR. This case highlights the importance of repeat neuroimaging in anticoagulated patients with new or worsening neurologic symptoms despite initially negative imaging, as well as the challenges of balancing hemorrhagic and thromboembolic risks during anticoagulation reversal and reinitiation.