title: Rapid Anticoagulation Reversal With Prothrombin Complex Concentrate Before Emergency Brain Tumor Surgery.
abstract: BACKGROUND
  Brain tumors may become symptomatic due to intracranial hypertension and patients may present to emergency departments in life-threatening conditions. Hence, emergency brain tumor surgery has to be considered, but sufficient hemostasis has to be present when initiating surgical procedures. Impaired hemostasis because of oral anticoagulation for the treatment of cardiovascular diseases is encountered in a growing number of patients. Here we present the first case series of anticoagulated patients receiving prothrombin complex concentrate (PCC) to rapidly restore hemostasis and facilitate emergency brain tumor surgery.
  
  
  METHODS
  We retrospectively analyzed our institutional database of neurosurgical patients receiving PCC from February 2007 to April 2013 (n=432) and identified 5 patients who received PCC before emergency brain tumor surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of hemostasis were analyzed.
  
  
  RESULTS
  Patients had a mean Glasgow Coma Scale score of 9.4 at admission. Mean international normalized ratio was 3.75±1.98 and after administration of PCC (mean, 3260±942 IU), international normalized ratio significantly decreased to 1.19±0.07 (P<0.0001). Emergency brain tumor surgery was initiated within 5.2 hours (range, 0 to 13.5 h) after PCC administration. Diagnostic histopathology revealed metastasis (n=2), meningioma (n=2), and ependymoma (n=1). No hemorrhagic or thromboembolic events occurred and 4 patients had a good neurological outcome at hospital discharge. One patient died on the 14th postoperative day because of respiratory failure following development of pneumonia.
  
  
  CONCLUSIONS
  In anticoagulated patients with brain tumors requiring immediate surgery due to life-threatening conditions, administration of PCC rapidly and safely restored hemostasis. PCC administration seems to be an effective option for anticoagulant reversal in this patient cohort. Further observational safety studies (eg, thromboembolic events) are warranted.
authors.affiliation: Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
authors.forename: Christopher
authors.initials: C
authors.lastname: Beynon
authors.forename: Anna
authors.initials: A
authors.lastname: Potzy
authors.forename: Christine
authors.initials: C
authors.lastname: Jungk
authors.forename: Andreas W
authors.initials: AW
authors.lastname: Unterberg
authors.forename: Oliver W
authors.initials: OW
authors.lastname: Sakowitz
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D001777:Blood Coagulation / Q000187:drug effects; D001779:Blood Coagulation Factors / Q000494:pharmacology*; D001932:Brain Neoplasms / Q000150:complications* / Q000601:surgery*; D002318:Cardiovascular Diseases / Q000150:complications* / Q000188:drug therapy*; D004638:Emergency Treatment / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors; C025667:prothrombin complex concentrates