Intracranial hemorrhage associated with direct oral anticoagulant after clipping for an unruptured cerebral aneurysm: A report of two cases.
Intracranial hemorrhage associated with direct oral anticoagulant after clipping for an unruptured cerebral aneurysm: A report of two cases.
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DOI：
10.25259/sni_1223_2021
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发表时间：
2022
影响因子：
--
通讯作者：
Ogasawara K
中科院分区：
文献类型：
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作者：
Koji T;Kubo Y;Matsumoto Y;Akamatsu Y;Chida K;Kashimura H;Ogasawara K
报告了两例未破裂脑动脉瘤（uAN）夹闭术后发生颅内出血的患者，这些患者与直接口服抗凝剂（DOAC）使用相关。这些病例将有助于神经外科医生评估需要开颅手术的房颤或深静脉血栓形成患者接受DOAC的风险。病例1是一名接受阿哌沙班10 mg/天治疗的65岁男性，因左侧大脑中动脉uAN接受夹闭术。术前72小时停用阿哌沙班。术中，额叶1个点处有一条薄软脑膜动脉轻微流血的，很容易止血。术后19小时的计算机断层扫描（CT）显示无颅内出血证据。术后29 h至41 h，患者接受肝素-阿哌沙班桥接治疗。24小时后CT显示左侧蛛网膜下腔血肿。病例2是一例73岁女性，接受达比加群110 mg/天治疗，因右侧MCA uAN接受夹闭术。术前48小时停用达比加群。术中，颞叶2个点处有一条细软脑膜动脉轻微流血的，止血很容易。术后19 h CT显示无颅内出血证据。术后29小时重新开始达比加群（110 mg/天）治疗。94小时后CT显示右侧蛛网膜下腔血肿，停用达比加群，38小时后重新开始。然而，31小时后，CT显示额外的轻微蛛网膜下腔出血。最后，患者出现右侧慢性硬膜下血肿。在接受神经外科手术的患者中，应根据神经外科出血风险和患者肾功能个体化停用DOAC。至少48小时后，当止血成功时，可考虑重新启动DOAC。不建议桥接DOAC。
Two cases of patients who developed intracranial hemorrhage associated with direct oral anticoagulant (DOAC) use after clipping of an unruptured cerebral aneurysm (uAN) are presented. These cases will help neurosurgeons assess the risks of patients with atrial fibrillation or deep venous thrombosis receiving DOACs who require craniotomy. Case 1 was a 65-year-old man on apixaban 10 mg/day who underwent clipping for a left middle cerebral artery uAN. Apixaban was discontinued 72 h before surgery. During surgery, a thin and pial artery bled slightly at 1 point of the frontal lobe, and hemostasis was easily achieved. Computed tomography (CT) 19 h after surgery showed no evidence of intracranial hemorrhage. He was treated with a heparin-apixaban bridge from 29 h to 41 h after surgery. CT showed a left subarachnoid hematoma 24 h later. Case 2 was a 73-year-old woman on dabigatran 110 mg/day who underwent clipping for a right MCA uAN. Dabigatran was discontinued 48 h before surgery. During surgery, a thin and pial artery bled slightly at 2 points of the temporal lobe, and hemostasis was easily achieved. CT 19 h after surgery showed no evidence of intracranial hemorrhage. Dabigatran (110 mg/day) was restarted 29 h after surgery. CT then showed a right subarachnoid hematoma 94 h later, and dabigatran was discontinued, and it was then restarted 38 h later. However, 31 h later, CT showed an additional slight subarachnoid hemorrhage. Finally, she developed a right chronic subdural hematoma. In patients undergoing neurosurgical procedures, discontinuation of DOACs should be individualized based on neurosurgical bleeding risk and patient renal function. Restarting of DOACs could be considered after at least 48 h when hemostasis has been achieved. Bridging of DOACs cannot be recommended.