Elsevier

World Neurosurgery

Volume 109, January 2018, Pages 432-435
World Neurosurgery

Case Report
Safe Burr Hole Surgery for Chronic Subdural Hematoma Using Dabigatran with Idarucizumab

https://doi.org/10.1016/j.wneu.2017.10.043Get rights and content

Background

Chronic subdural hematoma (CSDH) is a common intracranial hematoma. The number of patients who undergo anticoagulant therapy including a direct oral anticoagulant (DOAC) is expected to increase. Recently, idarucizumab, the antidote for dabigatran, which is a DOAC, has been developed. We successfully treated CSDH with dabigatran using emergency burr hole surgery and idarucizumab.

Case Description

A 79-year-old Japanese man severely hit his head and visited the emergency department. Computed tomography (CT) showed tiny traumatic acute subdural hematoma, for which he was admitted. At that time, atrial fibrillation was newly detected, for which dabigatran, having a specific antidote (idarucizumab), was chosen and started 2 weeks after the discharge. Two months after the trauma episode, he revisited the emergency department because of acute left upper and lower limb motor weakness. CT revealed a midline shifted CSDH. Considering rush course of motor weakness and shifted brain, we performed emergency surgery using an antidote for dabigatran, idarucizumab. He was discharged 5 days after surgery without any complications or excessive perioperative hemorrhage.

Conclusion

Dabigatran should be used for atrial fibrillation detected after head trauma. Emergency surgery can be safely performed for CSDH with dabigatran using idarucizumab.

Introduction

Chronic subdural hematoma (CSDH) is a common intracranial hematoma located between the dura mater and pia mater. It is conventionally reported to be related to aging and head trauma,1, 2 and its prevalence is expected to increase.

Elderly people are more likely to use anticoagulant drugs due to their higher prevalence of atrial fibrillation (AF) and cardiovascular or valvar surgery.3, 4 It has been reported that the incidence of CSDH has increased.5 Therefore the number of CSDH patients using anticoagulant therapy is expected to increase.1, 6 Additionally, vitamin K antagonist (VKA) is demonstrated to create a high risk for massive intracranial hemorrhage and fatality if it is not discontinued during the perioperative period.7

Direct oral anticoagulants (DOACs) comprise a new anticoagulant group, and the number of patients receiving it has increased.3, 4 In addition, anticoagulant therapies such as VKA or DOACs increase the risk of CSDH. Although there are no studies or reports indicating that perioperative continuous DOAC use induces massive intracranial hemorrhage after simple drainage surgery for CSDH, theoretically, DOACs are assumed to create at least some risk for postoperative massive hemorrhages, which could be fatal. VKA, which is an anticoagulant agent used with fresh-frozen plasma (FFP) transfusion, prothrombin complex concentrate, and recombinant factor VIIa, can reduce the possibility of postoperative massive intracranial hemorrhage.8, 9 Previously, there has been no inhibitor against DOACs. Recently, a humanized fragment antigen binding (Fab) antibody fragment named idarucizumab was developed as the antidote for 1 DOAC, dabigatran, in 2015. It has already been shown that this antidote is effective for controlling bleeding,10 and it has been prescribed in Japan since 2016. We report an educative and relatively rare case of CSDH with dabigatran treatment. Emergency burr hole surgery was safely performed using idarucizumab, which reduced the perioperative risk of hemorrhage.

Section snippets

Case Report

A 79-year-old Japanese man with hypertension fell down stairs and severely hit his head. He visited the emergency department at our hospital, where computed tomography (CT) revealed a tiny acute traumatic subarachnoid hemorrhage (Figure 1A). He was admitted to our hospital for 2 days of observation. During the admission period, AF was newly detected by the cardiac pulse monitor. Because the CHADS2 score was 2 points, which highly recommends anticoagulant therapy,11 a DOAC was started at the

Discussion

For the first time, we directly demonstrated effective and successful usage of Idarucizumab for surgery in the case of CSDH with dabigatran treatment. To the best of our knowledge, burr hole surgery for CSDH with dabigatran using idarucizumab has not been reported. Additionally, the present case suggests that dabigatran may be appropriate for trauma patients with AF if necessary. Idarucizumab, the specific antidote for dabigatran, might reduce perioperative massive hemorrhage with DOACs and

Conclusion

We have shown a successfully treated case of CSDH, under treatment with dabigatran, using emergency burr hole surgery and regression of anticoagulant therapy with idarucizumab. Dabigatran should be used for AF detected after head trauma.

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    Conflict of interest statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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