Neurosurgical complications of direct thrombin inhibitors--catastrophic hemorrhage after mild traumatic brain injury in a patient receiving dabigatran

• Published in: Journal of neurosurgery Vol. 116; no. 5; p. 1093
• Main Authors: Garber, Sarah T, Sivakumar, Walavan, Schmidt, Richard H
• Format: Journal Article
• Language: English
• Published: United States 01.05.2012
• Subjects: Aged, 80 and over; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Benzimidazoles - adverse effects; Benzimidazoles - therapeutic use; beta-Alanine - adverse effects; beta-Alanine - analogs & derivatives; beta-Alanine - therapeutic use; Brain Hemorrhage, Traumatic - chemically induced; Brain Hemorrhage, Traumatic - etiology; Brain Injuries - complications; Dabigatran; Factor VII - therapeutic use; Fatal Outcome; Glasgow Coma Scale; Humans; International Normalized Ratio; Male; Partial Thromboplastin Time; Subarachnoid Hemorrhage - etiology; Thrombin - antagonists & inhibitors; Tomography, X-Ray Computed
• ISSN: 1933-0693
• DOI: 10.3171/2012.2.jns112132

Dabigatran etexilate is an oral anticoagulant that acts as a direct, competitive thrombin inhibitor. Large randomized clinical trials have shown higher doses of dabigatran (150 mg taken twice daily) to be superior to warfarin in terms of stroke and systemic embolism rates in patients with nonvalvular atrial fibrillation. As a result, in 2010 the US FDA approved the use of dabigatran for the prevention of stroke and systemic embolism in patients with atrial fibrillation. Dabigatran is especially attractive in the outpatient setting because patients do not require routine monitoring with prothrombin times or international normalized ratios. To date, no effective reversal agent for dabigatran in the event of catastrophic hemorrhage has been identified. The authors report a case of an elderly patient, being treated with dabigatran for atrial fibrillation, who presented with a rapidly expanding intracranial hemorrhage after a ground-level fall. This case highlights an impending neurosurgical quandary of complications secondary to this new anticoagulation agent and suggests potential options for management.