Correction of prothrombin time in Neurosurgical patients



INR value of < 1.5 in the absence of bleeding does not require attempted correction prior to invasive procedures

The use of the fresh frozen plasma (FFP) in the perioperative period is a major contraversive subject. Neurosurgeons are very paranoid about mild alteration of prothrombin time and they tend to transfuse even for minor alteration of PT and INR. Recent studies (1) showed that there is no increase in the risk of bleeding in patients with PT or INR values within 1.5–1.8 times. They also found that FFP transfusions in patients with an INR < 1.7 do not reduce the INR. The recent data showed mildly elevated INR (< 1.7) have hemostatically normal levels of important coagulation factors. This guideline has led to a > 75% reduction in plasma therapy.

Other authors (2) suggested that the current indications for FFP transfusions are active bleeding or invasive procedure & INR >1.5 or aPTT >50 sec; coagulopathy after transfusion of >10 U RBCs; antithrombin deficiency and urgent reversal of warfarin effect. FFP transfusion may outweigh its benefit. First, there are risks associated with blood component transfusion, such as transfusion-related acute lung injury and infection. Second, the processes of laboratory testing and transfusion may impose a significant delay on necessary procedures. Thus INR value of < 1.5, in the absence of bleeding, does not require attempted correction prior to invasive procedures and the value between 1.5-1.7 still remains as a grey zone.


  1. Coagulation factor levels in neurosurgical patients with mild prolongation of prothrombin time: effect on plasma transfusion therapy. JNS January 2011.
  2. Prophylactic correction of the international normalized ratio in neurosurgery: a brief review of a brief literature. JNS January 2011

Dr. Manikandan is a NCR based Neurosurgeon. He obtained his MCh (Neurosurgery) from Christian Medical College, Vellore. His special interests include skull base, cerebrovascular and spine neurosurgery. 


Monday, October 13, 2014