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Safety and efficacy of prothrombin complex concentrate (PCC) for anticoagulation reversal in patients undergoing urgent neurosurgical procedures: a systematic review and metaanalysis

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Abstract

Anticoagulant therapy poses a significant risk for patients undergoing emergency neurosurgery procedures, necessitating reversal with prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Data on PCC efficacy lack consistency in this setting. This systematic review and metaanalysis aimed to evaluate efficacy and safety of PCC for anticoagulation reversal in the context of urgent neurosurgery. Articles from PubMed, Embase, and Cochrane databases were screened according to the PRISMA checklist. Adult patients receiving anticoagulation reversal with PCC for emergency neurosurgical procedures were included. When available, patients who received FFP were included as a comparison group. Pooled estimates of observational studies were calculated for efficacy and safety outcomes via random-effects modeling. Initial search returned 4505 articles, of which 15 studies met the inclusion criteria. Anticoagulants used included warfarin (83%), rivaroxaban (6.8%), phenprocoumon (6.1%), apixaban (2.2%), and dabigatran (1.5%). The mean International Normalized Ratio (INR) prePCC administration ranged from 2.3 to 11.7, while postPCC administration from 1.1 to 1.4. All-cause mortality at 30 days was 27% (95%CI 21, 34%; I2 = 44.6%; p-heterogeneity = 0.03) and incidence of thromboembolic events was 6.00% among patients treated with PCC (95%CI 4.00, 10.0%; I2 = 0%; p-heterogeneity = 0.83). Results comparing PCC and FFP demonstrated no statistically significant differences in INR reversal, mortality, or incidence of thromboembolic events. This metaanalysis demonstrated adequate safety and efficacy for PCC in the reversal of anticoagulation for urgent neurosurgical procedures. There was no significant difference between PCC and FFP, though further trials would be useful in demonstrating the safety and efficacy of PCC in this setting.

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  1. Rania A Mekary and Adomas Bunevicius are co-senior authors.

Authors and Affiliations

  1. University of New South Wales, Sydney, NSW, 2052, Australia

    Harrison Faulkner

  2. School of Pharmacy, MCPHS University, Boston, MA, 02115, USA

    Shubham Chakankar, Joanne Doucette, Nawaf Al-otaibi, Judi Abboud, Andrew Le & Rania A. Mekary

  3. Neurosurgery Unit, Department of Neurosciences, University of Turin, via Cherasco 15, 10126, Turin, Italy

    Marco Mammi & Rania A. Mekary

  4. Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA, 02115, USA

    Jack Yu Tung Lo

  5. Department of Neurosurgery, National Neuroscience Institute, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore

    Jack Yu Tung Lo

  6. Lithuanian University of Health Sciences, Kaunas, Lithuania

    Adomas Bunevicius

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Faulkner, H., Chakankar, S., Mammi, M. et al. Safety and efficacy of prothrombin complex concentrate (PCC) for anticoagulation reversal in patients undergoing urgent neurosurgical procedures: a systematic review and metaanalysis. Neurosurg Rev 44, 1921–1931 (2021). https://doi.org/10.1007/s10143-020-01406-z

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