Intracranial hemorrhage associated with direct oral anticoagulant after clipping for an unruptured cerebral aneurysm: A report of two cases
- Department of Neurosurgery, Iwate Medical University, Yahaba, Iwate, Japan.
Yoshitaka Kubo, Department of Neurosurgery, Iwate Medical University, Yahaba, Iwate, Japan.
DOI:10.25259/SNI_1223_2021Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Takahiro Koji, Yoshitaka Kubo, Yoshiyasu Matsumoto, Yosuke Akamatsu, Kohei Chida, Hiroshi Kashimura, Kuniaki Ogasawara. Intracranial hemorrhage associated with direct oral anticoagulant after clipping for an unruptured cerebral aneurysm: A report of two cases. 25-Mar-2022;13:104
How to cite this URL: Takahiro Koji, Yoshitaka Kubo, Yoshiyasu Matsumoto, Yosuke Akamatsu, Kohei Chida, Hiroshi Kashimura, Kuniaki Ogasawara. Intracranial hemorrhage associated with direct oral anticoagulant after clipping for an unruptured cerebral aneurysm: A report of two cases. 25-Mar-2022;13:104. Available from: https://surgicalneurologyint.com/surgicalint-articles/11486/
Background: 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 Description: 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.
Conclusion: 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.
Keywords: Cerebral aneurysm, Clipping, Direct oral anticoagulant, Intracranial hemorrhage
Several previous studies including autopsy reports have demonstrated that the formation and growth of unruptured cerebral aneurysms that might result in subarachnoid hemorrhage increase with advancing age.[
Two cases of patients who underwent craniotomy for surgical clipping of unruptured cerebral aneurysms and developed intracranial hemorrhage associated with DOACs are presented. These cases will help neurosurgeons assess the risks of patients with Af or deep venous thrombosis receiving DOACs who require craniotomy.
A 65-year-old man was on apixaban 10 mg/day as a DOAC for embolic cerebral infarction in the left occipital lobe and cerebellum associated with paroxysmal nonvalvular Af. He has a CHADS2-VASc score[
Case 1 (a) During surgical clipping for an aneurysm (arrow) of the left middle cerebral artery, a thin and pial artery bleeds slightly at 1 point of the left frontal lobe (arrowheads), and hemostasis is easily achieved using cotton. (b) Computed tomography (CT) 19 h after surgery shows no evidence of intracranial hemorrhage. (c) CT 36 h after restarting apixaban (24 h after discontinuing the heparin-DOAC bridge) shows subarachnoid hemorrhage in the left Sylvian fissure. (d) CT 240 h after surgery shows no additional increase of the hematoma.
A 73-year-old woman was on dabigatran 110 mg/day as a DOAC for embolic cerebral infarction in the right frontal lobe with paroxysmal nonvalvular Af. She had a CHADS2-VASc score[
Case 2 (a) During surgical clipping for an aneurysm (arrow) of the right middle cerebral artery, a thin and pial artery bleeds slightly at 2 points of the right temporal lobe (arrowheads), and hemostasis is easily achieved using cotton. (b) Computed tomography (CT) 19 h after surgery shows no evidence of intracranial hemorrhage. (c) CT 94 h after restarting dabigatran shows subarachnoid hemorrhage in the right Sylvian fissure. (d) CT 864 h after surgery shows a right chronic subdural hematoma.
Although the present two patients underwent gentle surgical clipping for unruptured cerebral aneurysms, intracranial hemorrhage developed. According to a meta-analysis[
Therefore, it is important to determine when to discontinue and restart DOACs to avoid bleeding in invasive neurosurgical procedures. According to the previous reports,[
Two cases of patients who developed intracranial hemorrhage associated with DOAC use after surgical clipping for unruptured cerebral aneurysms were presented. These cases will help neurosurgeons assess risks in patients on DOACs requiring craniotomy.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
This work was partly supported by a Grant-in-Aid for Strategic Medical Science Research (S1491001) from the Ministry of Education, Culture, Sports, Science, and Technology of Japan, a Research Grant of Japanese National Hospital Organization Kamaishi Hospital and a grant from JSPS KAKENHI (21K09158).
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