title: Management Overview: Taking a Patient with Intracranial Hemorrhage Related to Direct Oral Anticoagulants to the Operating Room.
abstract: Options for anticoagulation have been expanding constantly during the past few years, providing a greater number of agents for prevention and management of thromboembolic disease. Although heparins and vitamin K antagonists (VKAs) has been used extensively for many decades, their narrow therapeutic range, interactions with other medications and food, and the need for routine monitoring of blood levels have led to the search for less problematic alternatives. Direct oral anticoagulants represent an important advance in anticoagulation therapy, directly inhibiting thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban) they represent an effective and safe alternatives to VKAs and heparins in the prevention and treatment of several thromboembolic disorders. DOCAs are associated with a low overall intracranial hemorrhage risk; however, life-threatening bleeding can occur. Reversal agents are approved for some and under development for others, concerns over the lack of antidotes or difficulty in obtaining them has tempered enthusiasm for their use because of the perception of better safety with heparins and VKAs as a result of the availability of effective reversal strategies. Appropriate use of these agents requires knowledge of their individual characteristics, mechanisms of action, pharmacokinetics, ways of monitoring, and when needed, manage patients in need of urgent surgery especially in life-threatening bleeds. This article provides a suggested comprehensive approach to manage patients with intracranial hemorrhage while on direct oral anticoagulants who require an urgent surgical intervention and who cannot wait for plasma concentration to decline.
authors.affiliation: Neurocritical Care Unit, Montreal Neurological Hospital, Montreal, Québec, Canada; Departments of Neurosurgery and Neurocritical Care, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia. Electronic address: Abdulrahman.Alturki@mail.mcgill.ca.
authors.forename: Abdulrahman
authors.initials: A
authors.lastname: Alturki
authors.affiliation: Neurocritical Care Unit, Montreal Neurological Hospital, Montreal, Québec, Canada; Department of Neurology, King Fahd Hospital of the University, University of Dammam, Al Khobar, Saudi Arabia.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Alamri
authors.affiliation: Neurocritical Care Unit, Montreal Neurological Hospital, Montreal, Québec, Canada; Department of Anesthesia, Montreal Neurological Hospital, Montreal, Québec, Canada.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Badawy
authors.affiliation: Neurocritical Care Unit, Montreal Neurological Hospital, Montreal, Québec, Canada.
authors.forename: Jeanne
authors.initials: J
authors.lastname: Teitelbaum
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects*; D019317:Evidence-Based Medicine; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced* / Q000150:complications / Q000601:surgery*; D009873:Operating Rooms; D010346:Patient Care Management; D061214:Patient Safety; D011300:Preoperative Care / Q000379:methods*; D013923:Thromboembolism / Q000150:complications / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants
keywords: Andexanet; Direct oral anticoagulants (DOCAs); Emergency Neurosurgery; Factor Xa inhibitors; Idarucizumab; Intracranial hemorrhage; Novel oral anticoagulant (NOAC); Thrombin inhibitors