Clopidogrel plavix of Noncontrast CT revealed a right temporal intraparenchymal hemorrhage with surrounding cerebral edema, as well as a small right subdural hematoma and a small area of SAH. There was also a small amount of left frontal lobe and left parietal lobe SAH. Initial laboratory values revealed an international normalized ratio of 1.4, a prothrombin time of 17.2 seconds, and a partial thromboplastin time of 43 seconds. Platelet counts were normal at 271. The thrombin time was also measured and found to exceed 150 seconds. The patient was admitted to the neurocritical care unit for serial neurological examinations. Approximately 2 hours after admission to the intensive care unit, the patient chemical library screening developed dysarthric speech, although he was still able to briskly follow commands. Repeat CT demonstrated significant interval progression of both the right parenchymal and left frontal hemorrhages. Although the neurosurgical team was aware of the limited options available for reversal of dabigatran, a weight based dose of recombinant factor VII was administered because it has a rapid onset of action.
The patient’s mental status continued to decline, however, and he required nattokinase 133876-92-3 emergency endotracheal intubation for a GCS score of 6.9 A fi nal C T scan, obtained only 6 hours after his initial presentation, showed extensive progression of the patient’s bilateral intraparenchymal hemorrhages, now encompassing most of the left hemisphere with 7 mm of left to right midline shift and effacement of the left lateral ventricle. After extensive discussion with the patient’s family regarding his poor neurological prognosis, the decision was made to transition the patient to comfort care. The patient died shortly thereafter. Discussion The recent approval of dabigatran by the US FDA for stroke and systemic embolism prevention in patients with atrial fibrillation presents a new dilemma for neurosurgeons. Patients rivaroxaban treated with dabigatran are often elderly individuals with multiple comorbidities. Imbalance and falls are common in this population, and intracranial hemorrhage resulting even from minor trauma may occur with increasing frequency as use of this drug becomes more widespread. Atrial fibrillation is characterized by a loss of organized atrial contraction, which can lead to stasis and thrombus formation.
In patients with nonvalvular atrial fibrillation, the annual risk of stroke can be calculated according to the CHADS2 criteria.7 Because thrombin plays a key role in fibrin clot formation and is essential to blood coagulation, it is an attractive target for pharmaceutical agents. Current anticoagulants such as unfractionated low molecular weight heparin and the vitamin K antagonist warfarin require frequent blood draws and dosing adjustments to ensure patients remain in a therapeutic range. Dabigatran is a synthetic thrombin inhibitor that binds directly to clot bound and free thrombin with high specificity.8 Pharmacokinetic highlights include 80% renal excretion and a serum half life of 12 17 hours. Because of its half life, which is shorter than that of warfarin, dabigatran is typically administered twice daily. It is not metabolized by cytochrome p450 isoenzymes and therefore is less likely to potentiate drug drug interactions. 8 In addition, because dabigatran.