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Idarucizumab as Antidote to Intracerebral Hemorrhage under Treatment with Dabigatran

View Article: PubMed Central - PubMed

ABSTRACT

Background and purpose: Non-vitamin K anticoagulants (NOAC) such as dabigatran have become important therapeutic options for the prevention of stroke. Until recently, there were only nonspecific agents to reverse their anticoagulant effects in a case of emergency. Idarucizumab, an antibody fragment targeting dabigatran, is the first specific antidote for a NOAC to be approved, but real-world experience is limited.

Methods: We report two cases of patients on dabigatran with acute intracerebral hemorrhage who received idarucizumab.

Results: In both cases, idarucizumab promptly reversed the anticoagulant effect of dabigatran and there was no hematoma expansion in follow-up imaging.

Conclusions: In addition to clinical and preclinical studies, our cases add to the experience regarding the safety and efficacy of idarucizumab. They show that idarucizumab may be an important safety option for patients on dabigatran in emergency situations.

No MeSH data available.


Related in: MedlinePlus

Case 1. Upper row: CT scan on admission shows extensive left lobar hemorrhage and sulcal blood. Middle row: follow-up CT about 10 h after admission. The patient's head was tilted during the scan, and slices are chosen to best compare the extent of hemorrhage, which is stable. Bottom row: on follow-up CT at week 12, hemorrhage has completely resolved.
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Figure 1: Case 1. Upper row: CT scan on admission shows extensive left lobar hemorrhage and sulcal blood. Middle row: follow-up CT about 10 h after admission. The patient's head was tilted during the scan, and slices are chosen to best compare the extent of hemorrhage, which is stable. Bottom row: on follow-up CT at week 12, hemorrhage has completely resolved.

Mentions: A 74-year-old woman was admitted with an acute onset of aphasia and right-sided hemiparesis (NIHSS on admission 18). She was last seen normal about 3 h earlier. Her medical history included atrial fibrillation, for which she had taken dabigatran 110 mg b.i.d. (the last dose about 9 h earlier). Further concomitant diseases included coronary heart disease and arterial hypertension. Blood pressure on admission was 180/80 mm Hg but rose subsequently to 230/120 mm Hg. CT on admission (Fig 1) showed a large (6.2 × 3.9 × 5.8 cm) lobar intracerebral hemorrhage in the left hemisphere. Laboratory findings showed very mildly elevated activated partial thromboplastin time (aPTT) of 30.3 s (normal range 15–30 s) and a moderately elevated thrombin time (TT) of 81.6 s (normal range 17–24 s). Creatinine was slightly elevated at 103.8 µmol/L (normal range 58.1–95.92 µmol/L), and creatinine clearance estimated according to the formula of Cockcroft and Gault was 66.8 mL/min. Dabigatran concentration on admission was measured by the Hemoclot® test and showed a result below the sensitivity range of the test (50 ng/mL). Idarucizumab was administered 45 min after arrival in the ER; when measured 3 h later, aPTT and TT were in the normal range (23.9 and 20.6 s, respectively). The patient was admitted to our stroke unit. Elevated blood pressure was treated aggressively to a target of below 140 mm Hg systolic BP. Further diagnostics did not reveal any cause of hemorrhage other than elevated blood pressure and anticoagulant treatment. During the clinical workup, no hematoma growth was detected. Sixteen days after admission, she was transferred to a rehabilitation unit. By that time, the aphasia had partially receded, but hemiparesis was still pronounced (NIHSS 9).


Idarucizumab as Antidote to Intracerebral Hemorrhage under Treatment with Dabigatran
Case 1. Upper row: CT scan on admission shows extensive left lobar hemorrhage and sulcal blood. Middle row: follow-up CT about 10 h after admission. The patient's head was tilted during the scan, and slices are chosen to best compare the extent of hemorrhage, which is stable. Bottom row: on follow-up CT at week 12, hemorrhage has completely resolved.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5121568&req=5

Figure 1: Case 1. Upper row: CT scan on admission shows extensive left lobar hemorrhage and sulcal blood. Middle row: follow-up CT about 10 h after admission. The patient's head was tilted during the scan, and slices are chosen to best compare the extent of hemorrhage, which is stable. Bottom row: on follow-up CT at week 12, hemorrhage has completely resolved.
Mentions: A 74-year-old woman was admitted with an acute onset of aphasia and right-sided hemiparesis (NIHSS on admission 18). She was last seen normal about 3 h earlier. Her medical history included atrial fibrillation, for which she had taken dabigatran 110 mg b.i.d. (the last dose about 9 h earlier). Further concomitant diseases included coronary heart disease and arterial hypertension. Blood pressure on admission was 180/80 mm Hg but rose subsequently to 230/120 mm Hg. CT on admission (Fig 1) showed a large (6.2 × 3.9 × 5.8 cm) lobar intracerebral hemorrhage in the left hemisphere. Laboratory findings showed very mildly elevated activated partial thromboplastin time (aPTT) of 30.3 s (normal range 15–30 s) and a moderately elevated thrombin time (TT) of 81.6 s (normal range 17–24 s). Creatinine was slightly elevated at 103.8 µmol/L (normal range 58.1–95.92 µmol/L), and creatinine clearance estimated according to the formula of Cockcroft and Gault was 66.8 mL/min. Dabigatran concentration on admission was measured by the Hemoclot® test and showed a result below the sensitivity range of the test (50 ng/mL). Idarucizumab was administered 45 min after arrival in the ER; when measured 3 h later, aPTT and TT were in the normal range (23.9 and 20.6 s, respectively). The patient was admitted to our stroke unit. Elevated blood pressure was treated aggressively to a target of below 140 mm Hg systolic BP. Further diagnostics did not reveal any cause of hemorrhage other than elevated blood pressure and anticoagulant treatment. During the clinical workup, no hematoma growth was detected. Sixteen days after admission, she was transferred to a rehabilitation unit. By that time, the aphasia had partially receded, but hemiparesis was still pronounced (NIHSS 9).

View Article: PubMed Central - PubMed

ABSTRACT

Background and purpose: Non-vitamin K anticoagulants (NOAC) such as dabigatran have become important therapeutic options for the prevention of stroke. Until recently, there were only nonspecific agents to reverse their anticoagulant effects in a case of emergency. Idarucizumab, an antibody fragment targeting dabigatran, is the first specific antidote for a NOAC to be approved, but real-world experience is limited.

Methods: We report two cases of patients on dabigatran with acute intracerebral hemorrhage who received idarucizumab.

Results: In both cases, idarucizumab promptly reversed the anticoagulant effect of dabigatran and there was no hematoma expansion in follow-up imaging.

Conclusions: In addition to clinical and preclinical studies, our cases add to the experience regarding the safety and efficacy of idarucizumab. They show that idarucizumab may be an important safety option for patients on dabigatran in emergency situations.

No MeSH data available.


Related in: MedlinePlus