Neurosurgical complications of direct thrombin inhibitors—catastrophic hemorrhage after mild traumatic brain injury in a patient receiving dabigatran

Case report

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Dabigatran etexilate is an oral anticoagulant that acts as a direct, competitive thrombin inhibitor. Large randomized clinical trials have shown higher doses of dabigatran (150 mg taken twice daily) to be superior to warfarin in terms of stroke and systemic embolism rates in patients with nonvalvular atrial fibrillation. As a result, in 2010 the US FDA approved the use of dabigatran for the prevention of stroke and systemic embolism in patients with atrial fibrillation. Dabigatran is especially attractive in the outpatient setting because patients do not require routine monitoring with prothrombin times or international normalized ratios. To date, no effective reversal agent for dabigatran in the event of catastrophic hemorrhage has been identified. The authors report a case of an elderly patient, being treated with dabigatran for atrial fibrillation, who presented with a rapidly expanding intracranial hemorrhage after a ground-level fall. This case highlights an impending neurosurgical quandary of complications secondary to this new anticoagulation agent and suggests potential options for management.

Abbreviations used in this paper:GCS = Glasgow Coma Scale; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Richard H. Schmidt, M.D., Ph.D., Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, Utah 84132. email:

Please include this information when citing this paper: published online March 6, 2012; DOI: 10.3171/2012.2.JNS112132.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Noncontrast head CT scans obtained in the emergency department showing right temporal intraparenchymal hemorrhage with associated subdural hemorrhage and SAH (left) and left frontal subarachnoid blood (right).

  • View in gallery

    Noncontrast head CT scans. A: Study obtained approximately 2.5 hours postadmission showing significant interval evolution of the patient's intracranial hemorrhage bilaterally. B: Study obtained 6 hours postadmission revealing significant further progression of the patient's intracranial hemorrhage.



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