RESUMEN
We report the case of a 76-year-old man who was diagnosed with advanced stage hepatocellular carcinoma and was treated with atezolizumab plus bevacizumab therapy. Two weeks after 1st dose, he presented with acute changes in consciousness followed by hypothermia. A cerebrospinal fluid test showed an elevated cell count, total protein, and albumin. Infectious, anatomical, endocrinal, and neoplastic etiologies were ruled out. Based on the findings, atezolizumab-induced encephalitis was suspected, and high dose steroid therapy was administered. The patient's conscious level and hypothermia recovered completely about 9 days after starting the steroids, and he recovered without any neurological sequelae. This case report reminds physicians that prompt administration of steroid treatment after early diagnosis of immune checkpoint inhibitor-related encephalitis is the key for patients to recover without apparent neurological sequelae.
Asunto(s)
Carcinoma Hepatocelular , Encefalitis , Hipotermia , Neoplasias Hepáticas , Hemorragia Subaracnoidea , Masculino , Humanos , Anciano , Carcinoma Hepatocelular/tratamiento farmacológico , Neoplasias Hepáticas/tratamiento farmacológico , Hematoma Subdural/inducido químicamente , Hematoma Subdural/diagnóstico por imagen , Bevacizumab/efectos adversos , Progresión de la Enfermedad , EsteroidesRESUMEN
INTRODUCTION: Elderly patients receiving antithrombotic treatment have a significantly higher risk of developing an intracranial hemorrhage when suffering traumatic brain injury (TBI), potentially contributing to higher mortality rates and worse functional outcomes. It is unclear whether different antithrombotic drugs carry a similar risk. OBJECTIVE: This study aims to investigate injury patterns and long-term outcomes after TBI in elderly patients treated with antithrombotic drugs. METHODS: The clinical records of 2999 patients ≥ 65 years old admitted to the University Hospitals Leuven (Belgium) between 1999 and 2019 with a diagnosis of TBI, spanning all injury severities, were manually screened. RESULTS: A total of 1443 patients who had not experienced a cerebrovascular accident prior to TBI nor presented with a chronic subdural hematoma at admission were included in the analysis. Relevant clinical information, including medication use and coagulation lab tests, was manually registered and statistically analyzed using Python and R. In the overall cohort, 418 (29.0%) of the patients were treated with acetylsalicylic acid before TBI, 58 (4.0%) with vitamin K antagonists (VKA), 14 (1.0%) with a different antithrombotic drug, and 953 (66.0%) did not receive any antithrombotic treatment. The median age was 81 years (IQR = 11). The most common cause of TBI was a fall accident (79.4% of the cases), and 35.7% of the cases were classified as mild TBI. Patients treated with vitamin K antagonists had the highest rate of subdural hematomas (44.8%) (p = 0.02), hospitalization (98.3%, p = 0.03), intensive care unit admissions (41.4%, p < 0.01), and mortality within 30 days post-TBI (22.4%, p < 0.01). The number of patients treated with adenosine diphosphate (ADP) receptor antagonists and direct oral anticoagulants (DOACs) was too low to draw conclusions about the risks associated with these antithrombotic drugs. CONCLUSION: In a large cohort of elderly patients, treatment with VKA prior to TBI was associated with a higher rate of acute subdural hematoma and a worse outcome, compared with other patients. However, intake of low dose aspirin prior to TBI did not have such effects. Therefore, the choice of antithrombotic treatment in elderly patients is of utmost importance with respect to risks associated with TBI, and patients should be counselled accordingly. Future studies will determine whether the shift towards DOACs is mitigating the poor outcomes associated with VKA after TBI.
Asunto(s)
Lesiones Traumáticas del Encéfalo , Fibrinolíticos , Humanos , Anciano , Anciano de 80 o más Años , Fibrinolíticos/efectos adversos , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/tratamiento farmacológico , Anticoagulantes , Aspirina , Hematoma Subdural/inducido químicamente , Hematoma Subdural/tratamiento farmacológico , Hematoma Subdural/complicaciones , Vitamina K , Estudios RetrospectivosRESUMEN
BACKGROUND AND PURPOSE: Subdural hematomas are an uncommon, but a serious, bleeding complication of antithrombotic therapies. We update our previous inconclusive meta-analysis to better estimate the risk of subdural hematoma associated with aspirin use. METHODS: For the initial meta-analysis, nine randomized trials published between1980 and 2012 comparing aspirin with placebo/control were considered. Additional data from four large primary prevention trials were added. Two reviewers independently extracted data on subdural hematomas, with differences resolved by joint review and consensus. RESULTS: Numbers of subdural hematoma were available from thirteen randomized trials involving 155,554 participants comparing aspirin (dosage range 25 mg twice daily to 325 mg daily) to placebo (ten double-blind trials) or no aspirin (three trials). Participants included healthy healthcare providers, older people with vascular risk factors without manifest vascular disease, and those with atrial fibrillation or chronic angina. Pooling all trials, subdural hematomas were identified in 93 of 77,698 participants assigned to aspirin versus 62 of 77,856 participants assigned to placebo/no aspirin. By meta-analysis, the relative risk ratiometa of subdural hematoma associated with assignment to aspirin was 1.5 (95%CI 1.1, 2.0, p = 0.01; p = 0.9 for heterogeneity, I2 index = 0%). Based on recent primary prevention trials, subdural hematoma diagnosis averaged 1 per 3,125 people per year without aspirin use; the absolute increase associated with aspirin use was estimated as one additional subdural hematoma per 6,500 patients annually. CONCLUSIONS: This meta-analysis confirms that aspirin use increases the relative risk of subdural hematoma, but the absolute increased rate associated with aspirin therapy is very low for most people.
Asunto(s)
Aspirina/efectos adversos , Fibrinolíticos/efectos adversos , Hematoma Subdural/inducido químicamente , Anciano , Femenino , Hematoma Subdural/diagnóstico por imagen , Hematoma Subdural/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de RiesgoRESUMEN
RATIONALE: Idarucizumab is a specific reversal agent for patients with bleeding related to the anticoagulant dabigatran. There are no prior descriptions of Idarucizumab administration in the prehospital setting for intracranial hemorrhage. PATIENT CONCERNS: An 82-year-old woman treated with dabigatran for atrial fibrillation developed acute focal weakness. This led to activation of emergency medical services and assessment in the mobile stroke unit (MSU). DIAGNOSIS: Computed tomography of the brain performed in the MSU revealed an acute subdural hematoma. INTERVENTIONS: The patient was treated with Idarucizumab in the MSU. OUTCOMES: The subdural hematoma was treated with a burr hole evacuation and the patient was discharged to a rehabilitation facility without residual focal neurological deficits. LESSONS: Idarucizumab can be used safely and effectively to treat dabigatran-associated intracranial hemorrhage in the prehospital setting.
Asunto(s)
Antitrombinas/efectos adversos , Dabigatrán/efectos adversos , Hematoma Subdural/inducido químicamente , Hematoma Subdural/tratamiento farmacológico , Administración Intravenosa , Anciano de 80 o más Años , Anticuerpos Monoclonales Humanizados/administración & dosificación , Anticuerpos Monoclonales Humanizados/uso terapéutico , Antitrombinas/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Dabigatrán/uso terapéutico , Servicios Médicos de Urgencia , Femenino , Hematoma Subdural/diagnóstico por imagen , Hematoma Subdural/cirugía , Humanos , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Trepanación/métodosRESUMEN
BACKGROUND: Since the approval of the oral factor Xa inhibitors, there have been concerns regarding the ability to neutralize their anticoagulant effects after intracranial hemorrhage (ICH). Multiple guidelines suggest using prothrombin complex concentrates (PCCs) in these patients on the basis of research that includes a limited number of patients with ICH. Given this, we aimed to evaluate the safety and efficacy of PCCs for factor Xa inhibitor-related ICH in a large, multicenter cohort of patients. METHODS: This was a multicenter, retrospective, observational cohort study of patients with apixaban- or rivaroxaban-related ICH who received PCCs between January 1, 2015, and March 1, 2019. The study had 2 primary analysis groups: safety and hemostatic efficacy. The safety analysis evaluated all patients meeting inclusion criteria for the occurrence of a thrombotic event, which were censored at hospital discharge or 30 days after PCC administration. Patients with intracerebral, subarachnoid, or subdural hemorrhages who had at least 1 follow-up image within 24 hours of PCC administration were assessed for hemostatic efficacy. The primary efficacy outcome was the percentage of patients with excellent or good hemostasis on the basis of the modified Sarode criteria. Secondary outcomes included an evaluation of in-hospital mortality, length of stay, infusion-related reactions, and thrombotic event occurrence during multiple predefined periods. RESULTS: A total of 663 patients were included and assessed for safety outcomes. Of these, 433 patients met criteria for hemostatic efficacy evaluation. We observed excellent or good hemostasis in 354 patients (81.8% [95% CI, 77.9-85.2]). Twenty-five (3.8%) patients had a total of 26 thrombotic events, of which 22 occurred in the first 14 days after PCC administration. One patient had documentation of an infusion-related reaction. For the full cohort of patients, in-hospital mortality was 19.0%, and the median intensive care unit and hospital lengths of stay were 2.0 and 6.0 days, respectively. CONCLUSIONS: Administration of PCCs after apixaban- and rivaroxaban-related ICH provided a high rate of excellent or good hemostasis (81.8%) coupled with a 3.8% thrombosis rate. Randomized, controlled trials evaluating the clinical efficacy of PCCs in patients with factor Xa inhibitor-related ICH are needed.
Asunto(s)
Factores de Coagulación Sanguínea/uso terapéutico , Inhibidores del Factor Xa/efectos adversos , Hematoma Subdural/tratamiento farmacológico , Hemostasis/efectos de los fármacos , Hemostáticos/uso terapéutico , Pirazoles/efectos adversos , Piridonas/efectos adversos , Rivaroxabán/efectos adversos , Hemorragia Subaracnoidea/tratamiento farmacológico , Anciano , Factores de Coagulación Sanguínea/efectos adversos , Femenino , Hematoma Subdural/inducido químicamente , Hematoma Subdural/diagnóstico por imagen , Hematoma Subdural/mortalidad , Hemostáticos/efectos adversos , Mortalidad Hospitalaria , Humanos , Trombosis Intracraneal/inducido químicamente , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Hemorragia Subaracnoidea/inducido químicamente , Hemorragia Subaracnoidea/diagnóstico por imagen , Hemorragia Subaracnoidea/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
Patients with mechanical heart valves are at high thrombotic risk and require warfarin. Among those developing intracranial hemorrhage, limited data are available to guide clinicians with antithrombotic reinitiation. This 13-patient case series of warfarin-associated intracranial hemorrhages found the time to reinitiate antithrombotic therapy (17 days, interquartile range 21.5 days), and changes to international normalized ratio targets were variable and neither correlated with the type, location, or etiology of bleed, nor the valve and associated thromboembolic risk. The initial presentation significantly impacted prognosis, and diligent assessment and follow-up may support positive long-term outcomes.
Asunto(s)
Anticoagulantes/uso terapéutico , Hemorragias Intracraneales/inducido químicamente , Tromboembolia/prevención & control , Warfarina/uso terapéutico , Anciano , Antifibrinolíticos/uso terapéutico , Válvula Aórtica , Aspirina/uso terapéutico , Factores de Coagulación Sanguínea/uso terapéutico , Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/terapia , Femenino , Prótesis Valvulares Cardíacas , Hematoma Subdural/inducido químicamente , Hematoma Subdural/terapia , Humanos , Relación Normalizada Internacional , Hemorragias Intracraneales/terapia , Masculino , Persona de Mediana Edad , Válvula Mitral , Plasma , Inhibidores de Agregación Plaquetaria/uso terapéutico , Embarazo , Estudios Retrospectivos , Hemorragia Subaracnoidea/inducido químicamente , Hemorragia Subaracnoidea/terapia , Hemorragia Subaracnoidea Traumática/inducido químicamente , Hemorragia Subaracnoidea Traumática/terapia , Vitamina K/uso terapéuticoRESUMEN
Acute subdural hemorrhage (ASDH) is common and associated with severe morbidity and mortality. To date, the role of spontaneous cortical spreading depression (sCSD) in exaggerating secondary injury after ASDH, is poorly understood. The present study contains two experimental groups: First, we investigated and characterized the occurrence of sCSD after subdural blood infusion (300 µL) via tissue impedance (IMP) measurement in a rat model. Second, we compared the occurrence and influence of sCSD on lesion growth and neurological deficit in the presence and absence of whole blood constituents. In the first experimental group, three IMP traits could be distinguished after ASDH: no sCSD, recurrent sCSD, and constant elevated IMP (anoxic depolarization [AD]). In the second experimental group, sCSD occurred more often after autologous blood, compared with paraffin oil infusion. Lesion volume 7 days post-ASDH was 27.3 ± 6.8 mm3 after blood and 3.4 ± 2.1 mm3 after paraffin oil infusion. Subgroup analysis showed larger lesion size in animals with sCSD, than in those without. Further, occurrence of sCSD led to worse neurological outcomes in both groups. sCSD occurs early after ASDH and does not depend on the presence of whole blood constituents. However, numbers and degree of sCSD are more frequent and severe after autologous blood infusion, compared with an inert volume substance. The occurrence of sCSD leads to lesion growth and worse neurological outcome. Thus, our data advocate close monitoring and targeted treatment of sCSD after ASDH evacuation.
Asunto(s)
Depresión de Propagación Cortical/fisiología , Hematoma Subdural/fisiopatología , Recuperación de la Función/fisiología , Animales , Proteínas Sanguíneas/toxicidad , Hematoma Subdural/inducido químicamente , Hematoma Subdural/patología , Masculino , Aceites/toxicidad , Parafina/toxicidad , RatasAsunto(s)
Pruebas de Coagulación Sanguínea , Inhibidores del Factor Xa/sangre , Hematoma Subdural/inducido químicamente , Rivaroxabán/sangre , Anciano , Fibrilación Atrial/tratamiento farmacológico , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/farmacología , Inhibidores del Factor Xa/uso terapéutico , Hemorragia/prevención & control , Humanos , Masculino , Tiempo de Protrombina , Rivaroxabán/efectos adversos , Rivaroxabán/uso terapéuticoRESUMEN
Apixaban is a factor Xa inhibitor which is a non-vitamin K dependent oral anticoagulant known tocause the lowest rate of intracranial bleeding among the same kind of inibitors. In this paper, we report a rare case in a 60-year-old man with a history of hypertension and oligodendroglioma on apixaban for deep venous thrombosis who presented to our hospital with decreased level of consciousness and slurred speech with rapid deterioration. We highlight the risk of subdural bleeding requiring immediate neurosurgical intervention due to apixaban, with literature review.
Asunto(s)
Inhibidores del Factor Xa/efectos adversos , Hematoma Subdural/inducido químicamente , Hematoma Subdural/terapia , Pirazoles/efectos adversos , Piridonas/efectos adversos , Trombosis de la Vena/tratamiento farmacológico , Factores de Coagulación Sanguínea/uso terapéutico , Transfusión Sanguínea , Craneotomía , Diagnóstico Diferencial , Inhibidores del Factor Xa/uso terapéutico , Hematoma Subdural/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Plasma , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Anfetamina/efectos adversos , Hematoma Subdural/inducido químicamente , Hemorragia Subaracnoidea/inducido químicamente , Trastornos Relacionados con Sustancias/fisiopatología , Tomografía Computarizada por Rayos X , Vasculitis del Sistema Nervioso Central/inducido químicamente , Adulto , Confusión/inducido químicamente , Femenino , Hematoma Subdural/fisiopatología , Humanos , Hemorragia Subaracnoidea/fisiopatología , Trastornos Relacionados con Sustancias/diagnóstico por imagen , Trastornos Relacionados con Sustancias/terapia , Resultado del Tratamiento , Vasculitis del Sistema Nervioso Central/fisiopatología , Vasculitis del Sistema Nervioso Central/terapiaAsunto(s)
Anticoagulantes/efectos adversos , Cuidados Críticos , Craniectomía Descompresiva/métodos , Hematoma Subdural/inducido químicamente , Estenosis de la Válvula Mitral/tratamiento farmacológico , Tomografía Computarizada por Rayos X , Anticoagulantes/uso terapéutico , Preescolar , Electrocardiografía , Femenino , Hematoma Subdural/diagnóstico por imagen , Hematoma Subdural/fisiopatología , Hematoma Subdural/cirugía , Humanos , Ictericia , Estenosis de la Válvula Mitral/congénito , Estenosis de la Válvula Mitral/fisiopatología , Neuroimagen , Prurito , Resultado del TratamientoRESUMEN
OBJECTIVE: To quantify the risk of intracranial bleeds (ICBs) associated with new use of prophylactic low-dose aspirin using a population-based primary care database in the United Kingdom. METHODS: A cohort of new users of low-dose aspirin (75-300 mg; n = 199,079) aged 40-84 years and a 1:1 matched cohort of nonusers of low-dose aspirin at baseline were followed (maximum 14 years, median 5.4 years) to identify incident cases of ICB, with validation by manual review of patient records or linkage to hospitalization data. Using 10,000 frequency-matched controls, adjusted rate ratios (RRs) with 95% confidence intervals (CIs) were calculated for current low-dose aspirin use (0-7 days before the index date [ICB date for cases, random date for controls]); reference group was never used. RESULTS: There were 1,611 cases of ICB (n = 743 for intracerebral hemorrhage [ICH], n = 483 for subdural hematoma [SDH], and n = 385 for subarachnoid hemorrhage [SAH]). RRs (95% CI) were 0.98 (0.84-1.13) for all ICB, 0.98 (0.80-1.20) for ICH, 1.23 (0.95-1.59) for SDH, and 0.77 (0.58-1.01) for SAH. No duration of use or dose-response association was apparent. RRs (95% CI) for ≥1 year of low-dose aspirin use were 0.90 (0.72-1.13) for ICH, 1.20 (0.91-1.57) for SDH, and 0.69 (0.50-0.94) for SAH. CONCLUSION: Low-dose aspirin is not associated with an increased risk of any type of ICB and is associated with a significantly decreased risk of SAH when used for ≥1 year.
Asunto(s)
Aspirina/efectos adversos , Hemorragia Cerebral/inducido químicamente , Hemorragia Cerebral/epidemiología , Medicina General , Hematoma Subdural/inducido químicamente , Hematoma Subdural/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Hemorragia Subaracnoidea/inducido químicamente , Hemorragia Subaracnoidea/epidemiología , Reino UnidoRESUMEN
RATIONALE: Bromadiolone, often called a super-warfarin, is a potent rodenticide with long half-life. Skin and mucosal bleeding is the most common clinical manifestations of its intoxication. Bromadiolone intoxications in adults and children have been reported, but this phenomenon is rarely seen in fetuses. This paper presents a case of neonate with massive intracranial hemorrhage mediated by bromadiolone intoxication, highlighting that the bromadiolone is potentially lethal to the fetus. PATIENT CONCERNS: The male neonate presented with poor respiratory effort, decreased muscle tone, and pallor at birth. He developed generalized seizures on day 1 of life. His mother suffered from bleeding of oral mucosa and the subsequent lab screening for toxicants showed a bromadiolone level of 126âng/mL. DIAGNOSES: Laboratory tests revealed that prolonged prothrombin time (PT) and activated partial thromboplastin time (aPTT). A computed tomography (CT) of his head revealed a severe subdural hematoma, which lead to midline shift, bilateral intraventricular hemorrhage, and subarachnoid hemorrhage. Serum from cord blood was collected and screened for toxicants. The result returned with a bromadiolone level of 94âng/mL. INTERVENTIONS: The neonate was treated with vitamin K, fresh-frozen plasma, and red blood cells. OUTCOMES: His parents required termination of all treatments, and the neonate unfortunately died shortly after. LESSONS: Through clinical experience from this case, we believe that bromadiolone can be passed down to the fetus via placenta. Neonatal intracranial hemorrhage caused by bromadiolone is rare but potentially lethal. Pregnant women should be informed of the serious side effects of bromadiolone and this poisonous reagent should be avoided in any period during pregnancy.
Asunto(s)
4-Hidroxicumarinas/efectos adversos , Anticoagulantes/efectos adversos , Hematoma Subdural/inducido químicamente , Efectos Tardíos de la Exposición Prenatal/inducido químicamente , Hemorragia Subaracnoidea/inducido químicamente , Femenino , Humanos , Recién Nacido , Masculino , Tiempo de Tromboplastina Parcial , EmbarazoAsunto(s)
Anticoagulantes/efectos adversos , Fibrilación Atrial/tratamiento farmacológico , Hemorragia Cerebral/inducido químicamente , Infarto Cerebral/tratamiento farmacológico , Hematoma Subdural/inducido químicamente , Infarto del Miocardio/tratamiento farmacológico , Hemorragia Subaracnoidea/inducido químicamente , Administración Oral , Anticoagulantes/uso terapéutico , Estudios de Cohortes , Alemania , Humanos , Recurrencia , Factores de RiesgoRESUMEN
Essentials Intracranial bleeds (ICB) are serious clinical events that have been associated with aspirin use. Incidence rates of ICB were calculated among new-users of low-dose aspirin in the UK (2000-2012). Over a median follow-up of 5.58 years, the incidence of ICB was 0.08 per 100 person-years. Our estimates are valuable for inclusion in risk-benefit assessments of low-dose aspirin use. SUMMARY: Background Low-dose aspirin protects against both ischemic cardiovascular (CV) events and colorectal cancer (CRC). However, low-dose aspirin may be associated with a slightly increased risk of intracranial bleeds (ICBs). Objectives To obtain the incidence rates of ICBs overall and by patient subgroups among new users of low-dose aspirin. Patients/Methods Using The Health Improvement Network (THIN) UK primary-care database (2000-2012), we identified a cohort of new users of low-dose aspirin aged 40-84 years (N = 199 079; mean age at start of follow-up, 63.9 years) and followed them for up to 14 years (median 5.58 years). Incident ICB cases were identified and validated through linkage to hospitalization data and/or review of THIN records with free-text comments. Incidence rates with 95% confidence intervals (CIs) were calculated. Results Eight hundred and eighty-one incident ICBs cases were identified: 407 cases of intracerebral hemorrhage (ICH), 283 cases of subdural hematoma (SDH), and 191 cases of subarachnoid hemorrhage (SAH). Incidence rates per 100 person-years were 0.08 (95% CI 0.07-0.08) for all ICBs, 0.04 (95% CI 0.03-0.04) for ICH, 0.03 (95% CI 0.02-0.03) for SDH, and 0.02 (95% CI 0.01-0.02) for SAH. The ICB incidence rates per 100 person-years for individuals with an indication of primary CV disease prevention were 0.07 (95% CI 0.06-0.07) and 0.09 (95% CI 0.08-0.10) for secondary CV disease prevention. Incidence rates were higher in men for SDH, and higher in women for ICH and SAH. Conclusions Our results provide valuable estimates of the absolute ICB risk for incorporation into risk-benefit assessments of low-dose aspirin use.
Asunto(s)
Aspirina/efectos adversos , Hemorragias Intracraneales/inducido químicamente , Hemorragias Intracraneales/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Hematoma Subdural/inducido químicamente , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Medición de Riesgo , Hemorragia Subaracnoidea/inducido químicamente , Reino UnidoRESUMEN
Dasatinib has been associated with an increased risk of bleeding, with the most prominent risk noted in patients with advanced-stage chronic myeloid leukemia and thrombocytopenia. We herein report two cases of Philadelphia chromosome-positive acute lymphoblastic leukemia in which a subdural hematoma developed in association with low-dose (40-50 mg/day) dasatinib treatment and lumbar puncture for intrathecal methotrexate injection. Both patients were in complete remission, with normal platelet counts and coagulation status. We suggest that dasatinib, even at a low dose, may impair platelet aggregation and that lumbar puncture may increase the risk of a subdural hematoma (occasionally bilateral) in patients receiving dasatinib.
Asunto(s)
Antineoplásicos/efectos adversos , Dasatinib/efectos adversos , Hematoma Subdural/inducido químicamente , Metotrexato/efectos adversos , Cromosoma Filadelfia , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamiento farmacológico , Anciano , Antineoplásicos/uso terapéutico , Dasatinib/uso terapéutico , Femenino , Humanos , Inyecciones Espinales , Metotrexato/uso terapéuticoAsunto(s)
Anticoagulantes/efectos adversos , Hemorragia Cerebral/inducido químicamente , Hematoma Subdural/inducido químicamente , Errores de Medicación/efectos adversos , Anciano , Hemorragia Cerebral/diagnóstico por imagen , Femenino , Hematoma Subdural/diagnóstico por imagen , Humanos , Medición de Riesgo , Tomografía Computarizada por Rayos X , WarfarinaRESUMEN
OBJECTIVE: To report 3 cases of subdural bleeding associated with rivaroxaban managed by 3-factor prothrombin complex concentrate (PCC3). CASE SUMMARIES: Case 1 presented with a 1-cm thick subdural hematoma (SDH) 12 hours after her last dose of rivaroxaban. Case 2 presented with a right 1-cm acute right SDH with 2 to 3 mm of midline shift 24 hours after his last dose of rivaroxaban. Case 3 presented with a 1.8-cm thick right cerebral convexity hematoma 12 hours after her last dose of rivaroxaban. All patients received 23 to 35 units/kg PCC3 with 1 to 3 units of fresh frozen plasm (FFP) and demonstrated no progression in lesions measured by repeat computed tomography (CT). Two patients were discharged to rehabilitation facilities and 1 patient ultimately died due to the location of the lesion. DISCUSSION: Rivaroxaban has no specific antidote. Current bleeding management strategies are based on expert opinion. The risks and benefits for differing strategies are unclear, and no clinical experience has been reported to date. These cases begin to illuminate differences among choices for managing bleeding associated with Xa inhibitors. CONCLUSION: In this case series, 25 to 35 units/kilogram PCC3 and FFP 1 to 3 units ceased rivaroxaban-associated bleeding without thrombogenic complications.
Asunto(s)
Factores de Coagulación Sanguínea/uso terapéutico , Manejo de la Enfermedad , Inhibidores del Factor Xa/efectos adversos , Hematoma Subdural/inducido químicamente , Hematoma Subdural/tratamiento farmacológico , Rivaroxabán/efectos adversos , Anciano , Anciano de 80 o más Años , Animales , Femenino , Hematoma Subdural/diagnóstico , Hemorragia/inducido químicamente , Hemorragia/diagnóstico , Hemorragia/tratamiento farmacológico , Humanos , MasculinoRESUMEN
BACKGROUND: Oral anticoagulation is a common prophylactic therapy for several diseases with a high thromboembolic risk. Such medication harbors a possible hemorrhage risk, with a special risk for subdural hematoma (SDH). The safety and efficacy of resumption of oral anticoagulation versus long-term discontinuation has not been fully clarified in patients who experienced SDH while under treatment with oral anticoagulation. MATERIAL AND METHODS: We investigated the outcome of 49 patients who were identified retrospectively to have a SDH while receiving oral anticoagulation. RESULTS: Most bleeding occurred while patients were within the recommended therapeutic window for oral anticoagulation. Mortality was 15%. The event-free survival probability was higher in the group of patients with reinstitution of phenprocoumon therapy than in the group without. Over a median follow-up of 32 months, thromboembolic events occurred in 4 of 23 patients without oral anticoagulation versus in none of 15 patients with phenprocoumon; hemorrhagic complications occurred in 1 in 23 versus 3 in 15 patients. CONCLUSIONS: Reinstitution of oral anticoagulation with phenprocoumon after previous SDH appears to have an acceptable risk for hemorrhagic complications. Decision making might consider case-by-case differences. To establish specific guidelines, prospective large cohort studies are needed.
Asunto(s)
Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Hematoma Subdural/inducido químicamente , Hematoma Subdural/terapia , Anciano , Anciano de 80 o más Años , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Hematoma Subdural/mortalidad , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Fenprocumón/efectos adversos , Fenprocumón/uso terapéutico , Estudios Retrospectivos , Tromboembolia/prevención & control , Resultado del Tratamiento , Warfarina/efectos adversos , Warfarina/uso terapéuticoRESUMEN
The management of life-threatening bleeding associated with rivaroxaban remains a challenge for physicians due to the lack of evidence about clinically effective options for anticoagulation reversal. We report a favorable outcome in a patient receiving rivaroxaban prophylaxis, who developed a spontaneous subdural hematoma treated by a surgical evacuation and administration of 4-factor prothrombin complex concentrate. Classical coagulation variables were associated with impaired thrombin generation. Reversal with prothrombin complex concentrates improved all thrombin generation measures. Thrombin generation tests may be suitable for assessing the clinical utility of reversal drugs on rivaroxaban-induced coagulopathy.