Case ReportSafe Burr Hole Surgery for Chronic Subdural Hematoma Using Dabigatran with 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.