title: Utilization of recombinant activated factor VII for intracranial hematoma evacuation in coagulopathic nonhemophilic neurosurgical patients with normal international normalized ratios.
abstract: BACKGROUND
  Recombinant activated Factor VII (rFVIIa) has recently gained popularity for rapid reversal of coagulopathy during operative neurosurgery. Patients undergoing chronic subdural hematoma (CSDH) or epidural hematoma (EDH) evacuation often have their coagulation status judged by preoperative international normalized ratio (INR). We present our experience in two patients with significant clinical coagulopathy who were successfully reversed with rFVIIa in the setting of normal INR.
  
  
  METHODS
  Patient one was a 79-year-old man with history of prostate cancer and three previous operative left CSDH evacuations, each complicated by coagulopathic bleeding, who presented with new-onset left EDH. Patient two was a 27-year-old woman with relapsed acute myelogenous leukemia with bilateral CSDH and mass effect on MRI. Neither patient had hemophilia, and preoperative INR was 1.2 in each case. Both patients underwent evacuation in the operating room, preceded by rFVIIa administration.
  
  
  RESULTS
  Patient one underwent removal of his previous craniotomy flap followed by EDH evacuation. In patient two, coagulopathic bleeding upon surgical approach necessitated an additional dose of rFVIIa. Burrhole evacuation was well-tolerated with visible brain re-expansion following irrigation. Each case occurred with minimal blood loss and relatively easy hemostasis, with postoperative CT and clinical course revealing adequate evacuation. Neither patient experienced thromboembolic complications or required re-operation.
  
  
  CONCLUSIONS
  These two patients are the first to be examined for the use of rFVIIa for reversal of clinical coagulopathy in the setting of normal INR. Our experience suggests that normal INR should not be a deterrent for patients to receive rFVIIa in the setting of strong neurosurgical suspicion for underlying clinical coagulopathy.
authors.affiliation: Department of Neurosurgery, University of Minnesota, Mayo Mail Code 96, 420 Delaware Street SE, Minneapolis, MN 55455, USA. mccl0285@umn.edu
authors.forename: Shearwood
authors.initials: S
authors.lastname: McClelland
authors.forename: Eun Kyung
authors.initials: EK
authors.lastname: Won
authors.forename: Cornelius H
authors.initials: CH
authors.lastname: Lam
mesh_terms: D000328:Adult; D000368:Aged; D001778:Blood Coagulation Disorders / Q000188:drug therapy / Q000209:etiology; D003399:Craniotomy; D015942:Factor VIIa / Q000627:therapeutic use*; D005260:Female; D006407:Hematoma, Epidural, Cranial / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000601:surgery*; D020200:Hematoma, Subdural, Chronic / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000601:surgery*; D006801:Humans; D019934:International Normalized Ratio; D015470:Leukemia, Myeloid, Acute / Q000150:complications; D008297:Male; D011994:Recombinant Proteins / Q000627:therapeutic use; D014057:Tomography, X-Ray Computed
chemical_list: D011994:Recombinant Proteins; D015942:Factor VIIa