title: Management of dabigatran-associated intracerebral and intraventricular hemorrhage: a case report.
abstract: BACKGROUND
  Dabigatran is an oral, reversibly bound, direct thrombin inhibitor currently approved in the United States for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. In the phase III trial leading to approval of the agent, the incidence of life-threatening bleeding was 1.80%/year in the dabigatran 150 mg twice daily arm. Because there is no direct antidote or reversal agent for this drug, the need to manage life-threatening hemorrhages with procoagulant products will arise.
  
  
  OBJECTIVE
  To describe a case of dabigatran-associated intracerebral and intraventricular hemorrhage and subsequent management with activated prothrombin complex concentrate.
  
  
  METHODS
  An 85-year-old man currently taking dabigatran 150 mg twice daily presented to the Emergency Department for incoordination, expressive aphasia, and weakness. A computed tomography image of his head demonstrated an intracranial hemorrhage. The last dose of dabigatran was approximately 14 h prior to arrival, and conventional coagulation assays (thrombin time and activated partial thromboplastin time) confirmed the presence of dabigatran in the patient's serum. The patient received 27.5 units/kg of activated prothrombin complex concentrate (FEIBA®; Baxter Healthcare Corporation, Deerfield, IL) after an initial intravenous fluid bolus. His activated partial thromboplastin time was not completely normalized by the use of FEIBA; however, the patient's neurological examination slightly improved and remained stable throughout his hospital course despite some intraventricular expansion of the hematoma. After discharge to physical rehabilitation, the patient developed an ischemic cerebrovascular accident and was discharged home on hospice.
  
  
  CONCLUSIONS
  Due to lack of an available antidote, activated prothrombin complex concentrate was utilized as a nonspecific procoagulant to stabilize an intracerebral hemorrhage in a patient on dabigatran.
authors: Department of Pharmacy, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, Texas.
authors: Andrew C
authors: AC
authors: Faust
authors: Department of Pharmacy, Seton Medical Center Austin, Austin, Texas.
authors: Evan J
authors: EJ
authors: Peterson
mesh_terms: D000369:Aged, 80 and over; D000991:Antithrombins / Q000009:adverse effects*; D001562:Benzimidazoles / Q000009:adverse effects*; D001779:Blood Coagulation Factors / Q000627:therapeutic use*; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000188:drug therapy*; D000069604:Dabigatran; D006801:Humans; D008297:Male; D015091:beta-Alanine / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000991:Antithrombins; D001562:Benzimidazoles; D001779:Blood Coagulation Factors; D015091:beta-Alanine; C065655:anti-inhibitor coagulant complex; D000069604:Dabigatran
keywords: FEIBA; anticoagulation reversal; dabigatran; intracerebral hemorrhage; ischemic stroke