Delray Medical Center/Provisional Level I Trauma Center, Delray Beach, Florida, USA.
J Neurosurg. 2013 Sep;119(3):760-5. doi: 10.3171/2013.3.JNS12503. Epub 2013 May 1.
The direct thrombin inhibitor dabigatran has recently been approved in the US as an alternative to warfarin. The lack of guidelines, protocols, and an established specific antidote to reverse the anticoagulation effect of dabigatran potentially increases the rates of morbidity and mortality in patients with closed head injury (CHI). Confronted with this new problem, the authors reviewed their initial clinical experience.
The authors retrospectively reviewed all cases of adult patients (age ≥ 18 years) who sustained CHI secondary to ground-level falls and who presented to the authors' provisional regional Level I trauma center between February 2011 and May 2011. The authors divided these patients into 3 groups based on anticoagulant therapy: dabigatran, warfarin, and no anticoagulants.
Between February 2011 and May 2011, CHIs from ground-level falls were sustained by 5 patients while on dabigatran, by 15 patients on warfarin, and by 25 patients who were not on anticoagulants. The treatment of the patients on dabigatran at the authors' institution had great diversity. Repeat CT scans obtained during reversal showed 4 of 5 patients with new or expanded hemorrhages in the dabigatran group, whereas the warfarin group had 3 of 15 (p = 0.03). The overall mortality rate for patients sustaining CHI on dabigatran was 2 (40%) of 5, whereas that of the warfarin group was 0 (0%) of 15 (p = 0.05).
It is critical for physicians involved in the care of patients with CHI on dabigatran to be aware of an elevated mortality rate if no treatment protocol or guideline is in place. The authors will soon implement a reversal management protocol for patients with CHI on dabigatran at their institution in an attempt to improve efficacy and safety in their treatment approach.
直接凝血酶抑制剂达比加群最近已在美国获得批准，可作为华法林的替代品。由于缺乏指南、方案以及逆转达比加群抗凝作用的既定特效解毒剂，可能会增加闭合性颅脑损伤（CHI）患者的发病率和死亡率。面对这一新问题，作者回顾了他们的初步临床经验。
作者回顾性分析了 2011 年 2 月至 2011 年 5 月期间因地面坠落导致 CHI 并在作者所在的临时区域一级创伤中心就诊的所有成年患者（年龄≥18 岁）的病例。作者根据抗凝治疗将这些患者分为 3 组：达比加群、华法林和未使用抗凝剂。
2011 年 2 月至 2011 年 5 月期间，因地面坠落导致 CHI 的患者中，有 5 例正在使用达比加群，15 例正在使用华法林，25 例未使用抗凝剂。作者所在机构对使用达比加群的患者的治疗方法差异很大。在逆转过程中获得的重复 CT 扫描显示，达比加群组的 4/5 例患者出现新的或扩大的出血，而华法林组的 15/15 例患者有 3 例（p=0.03）。在使用达比加群的 CHI 患者中，总的死亡率为 5 例中的 2 例（40%），而华法林组为 15 例中的 0 例（0%）（p=0.05）。
如果没有治疗方案或指南，参与达比加群治疗的 CHI 患者的医生必须意识到死亡率会升高。作者将很快在他们所在的机构为使用达比加群的 CHI 患者实施逆转管理方案，以试图提高其治疗方法的疗效和安全性。
