Fatal warfarin-associated intracranial hemorrhage with intraventricular extension in a child with mechanical mitral valve presenting as persistent headache initially treated as acute sinusitis: a case report

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Pediatr Emerg Med J. 2026;13(3):115-118

Publication date (electronic) : 2026 May 18

doi : https://doi.org/10.22470/pemj.2026.01648

Çağdaş Derdiyok, Durmuş Gençer

Department of Emergency Medicine, Lüleburgaz State Hospital, Lüleburgaz, Türkiye

Corresponding author: Çağdaş Derdiyok Department of Emergency Medicine, Lüleburgaz State Hospital, İstanbul Caddesi 170, 39750 Lüleburgaz, Kırklareli, Türkiye Tel: +90-554-468-82-81; E-mail: drcagdasderdiyok@gmail.com

Received 2026 April 17; Revised 2026 May 6; Accepted 2026 May 7.

Abstract

Introduction

Mechanical mitral valve replacement in pediatric patients requires lifelong anticoagulation therapy to prevent thromboembolic complications (1). Warfarin remains the most widely used anticoagulant in the population despite its narrow therapeutic range and the requirement for regular monitoring (1).

Intracranial hemorrhage (ICH) represents the most severe complication associated with warfarin therapy and is often fatal (2). Headache may be the earliest presenting symptom of ICH; however, it may initially be misinterpreted as benign conditions such as acute bacterial sinusitis (ABS), especially in pediatric patients. Early neuroimaging should therefore be strongly considered in anticoagulated patients presenting with persistent headache, regardless of initial neurological examination findings (3).

Here, we present a fatal case of warfarin-associated ICH initially treated as ABS in primary care, highlighting persistent headache as an early warning sign requiring urgent neuroimaging in anticoagulated children. Written informed consent was obtained from the patient’s legal guardians. Ethics committee approval was waived for this case report.

Case

A 7-year-old female receiving long-term daily warfarin therapy at a recent dose of 2.5 mg presented to our emergency department with a 3-day history of severe headache accompanied by vomiting and progressive somnolence. Three days prior to the presentation, she was evaluated by a family physician due to her new-onset headache, and treated with oral antibiotics and antipyretics under a presumptive diagnosis of ABS. She was reportedly prescribed oral antibiotics and antipyretics. Although the exact medications could not be confirmed, amoxicillin-clavulanate, which is commonly used to treat ABS, may elevate the international normalized ratio (INR) through drug interaction with warfarin (2).

She had started the warfarin therapy with INR monitored monthly, after 2 valve replacement surgeries due to a congenital mitral stenosis, of which the latter was performed at the age of 3.5 years in a tertiary university hospital. At that time, the latest INR value was 2.60, measured 2 months earlier. She had been taking warfarin regularly as prescribed, with no history of overdose, noncompliance, or head injury reported.

The initial vital signs were as follows: blood pressure, 110/70 mmHg; heart rate, 110 beats/minute; respiratory rate, 20 beats/minute; temperature, 36.7 °C; and oxygen saturation, 93% (room air). She weighed 25 kg and was somnolent but arousable with a Glasgow Coma Scale of 12 (eye-opening, 3; verbal response, 4; and motor response, 5).

During observation, a progressive neurological deterioration occurred, and her Glasgow Coma Scale declined to 8 (eye-opening, 2; verbal response, 2; and motor response, 4). Rapid sequence intubation was performed using intravenous ketamine (1–2 mg/kg) and rocuronium (1 mg/kg).

Cranial computed tomography scan showed a 4.5 × 3.0 cm-sized intraparenchymal hematoma in the left parieto-occipital region with intraventricular extension involving all ventricles and associated prepontine subarachnoid hemorrhage (Figure). No additional sedative was given during the scan.

Figure.

Sagittal (A) and axial (B) non-contrast computed tomography scans. They show a left parieto-occipital intraparenchymal hematoma (asterisks) with midline shift and intraventricular extension involving the lateral (arrow, A) and third (arrow, B) ventricles.

Laboratory evaluation showed an INR of 5.03, platelet count of 576 × 10³/µL, and otherwise normal findings. Warfarin reversal was initiated with fresh frozen plasma (15 mL/kg), along with 3% saline (5 mL/kg bolus) and levetiracetam (20 mg/kg intravenously) (4).

Neurosurgical consultation was obtained; however, surgical intervention was deemed hopeless due to extensive intraventricular hemorrhage, severe coagulopathy, rapid neurological deterioration, and poor expected outcome (4). On the same day of the visit, she was transferred to a tertiary pediatric intensive care unit. At the intensive care unit, brain death was declared on day 9, and she died on day 12 despite intensive supportive treatment.

Discussion

Warfarin therapy remains essential in pediatric patients with mechanical mitral valves and requires strict INR monitoring (1). In this case, her INR reached 5.03, likely due to inadequate monitoring. According to the American College of Cardiology/American Heart Association guidelines, patients with mechanical mitral valves require lifelong anticoagulation with a target INR of approximately 3.0 (range, 2.5–3.5) (5). Additionally, drug interactions between warfarin and antibiotics might have contributed to supratherapeutic anticoagulation (2).

A key diagnostic pitfall was the initial misinterpretation of persistent headache as ABS. In anticoagulated patients, headache should be considered a symptom suggestive of ICH until proven otherwise (3). The 3-day delay illustrates how early symptoms may be underestimated in pediatric patients. Intraventricular extension worsens prognosis, particularly when all ventricles are involved (4). Four-factor prothrombin complex concentrate was not used due to limited availability and prohibitive cost; therefore, fresh frozen plasma was administered (4).

This case suggests that persistent headache in pediatric patients on warfarin therapy warrants immediate neuroimaging regardless of benign initial clinical findings. Intraventricular extension of ICH in the setting of supratherapeutic anticoagulation carries a poor prognosis. It is paramount to maintain INR within the therapeutic range through frequent monitoring, as well as to heighten awareness among primary care physicians regarding the bleeding risk associated with anticoagulation. Future efforts should focus on improving patient education, ensuring regular INR monitoring, and establishing clear protocols for early neuroimaging in anticoagulated children presenting with neurological symptoms.

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