Surgical treatment of traumatic intracranial hemorrhage in patients with novel oral anticoagulant (NOAC) administration: A report of three cases

Abstract

NOAC (novel oral anticoagulant) showed a lower incidence of intracranial hemorrhage compared to warfarin in several randomized trials. However, once intracranial hemorrhage occurs, there is no established treatment guideline for controlling intracranial bleeding in patients treated with NOAC. We experienced three cases of traumatic intracranial hemorrhage prompting urgent surgical treatment in patients with NOAC administration. Case 1 was an 82-year-old woman who underwent surgical removal of a traumatic intracerebral hemorrhage 20 hours after the last administration of dabigatran. Hemostasis was excellent and no blood transfusion was necessary. Case 2 was a 77-year-old man who had an acute subdural hemorrhage with midline shift. Although 17 hours had passed since last administration of rivaroxaban, activated partial thromboplastin time(APTT)was 74.9. He underwent surgery with administration of fresh frozen plasma(FFP) and prothrombin complex concentrate (PCC). He lost 400 ml of blood during the operation. Case 3 was a 78-year-old man with a 30-mm traumatic intracerebral hemorrhage and contusion in the right temporoparietal lobe. As 11 hours had already passed since head injury, he was first placed under observation in the intensive care unit. Three hours later, his consciousness decreased from Glasgow Coma Scale(GCS)of 14 to 8. CT revealed a 70-mm expanded hematoma in the same lesion. Surgery performed using FFP with minimal loss of blood and favorable hemostasis. The efficacy of PCC is still not clear, but careful observation with frequent CT or measurement of bleeding time as well as preparation of PCC and FFP is mandatory in head trauma patients treated with NOAC.