The diagnostic challenge of a vitamin K antagonist with dabigatran use triggering massive intracranial haemorrhage

Editor—We present the case of an 87-year-old patient who was admitted intubated and sedated to our emergency department after traumatic brain injury suspicious of open skull fracture (approved by the Ethical Committee of the Medical University of Vienna; EK Nr.: 1519/2016). The initial computed tomography (CT) scan showed no signs of intracranial haemorrhage or fractures, whereupon the patient was extubated. The anamnestic intake of phenprocoumon was reflected by an international normalized ratio within the therapeutic range. However, neither the considerably increased activated partial thromboplastin time (aPTT) nor the prolonged thrombin time (TT) were consistent with the intake of a vitamin K antagonist (VKA) (Table 1). Table 1Laboratory results, drug administration, and interventions shown in a time-dependent manner in days (d) and hours (h) since the patients admission (T0). aPTT: activated partial thromboplastin time; BUN: blood urea nitrogen; GFR: glomerular filtration rate; INR: international normalized ratio; LMWH: low molecular weight heparin; PPSB: prothrombin complex concentrate; CiCaCVVHD: calcium citrate anticoagulated continuous venovenous haemodialysisVariableUnit (SI unit)T₀ + 1 hT₀ + 15 hT₀ + 20 hT₀ + 1 d 14 hT₀ + 2 d 12 hT₀ + 2 d 18 hT₀ + 3 d 3 hT₀ + 3 d 14 hT₀ + 4 d 13 hT₀ + 5 d 14 hT₀ + 6 d 13 hT₀ + 7 d 13 hT₀ + 8 d 13 hThromboplastin time (Owren)%19225562757252545453565653INR 2.52.31.31.21.11.11.31.31.31.31.31.31.3aPTTs76.473.231.633.540.041.448.051.148.858.347.445.539.7Thrombin times>120>12018.118.635.556.294.890.062.347.827.623.120.3Fibrinogenmg dl ^-1 (g L^-1)353 (3.53)443 (4.43)413 (4.13)435 (4.35)462 (4.62)419 (4.19)314 (3.14)389 (3.89)449 (4.49)498 (4.98)560 (5.60)545 (5.45)610 (6.10)Antithrombin III activity%72946962666857647781837572Dabigatranng ml ^-1—100<30<30——<3050—————Creatininemg dl ^-1 (µmol L^-1)1.11 (98.24)1.21 (107.09)1.34 (118.59)2.15 (190.28)2.86 (253.11)3.02 (267.27)3.17 (280.55)3.47 (307.10)1.99 (176.12)1.02 (90.27)0.61 (53.99)0.55 (48.68)0.58 (51.33)BUNmg dl^-1 (mmol L^-1)—15.2 (2.538)15.0 (2.505)23.9 (3.991)29.9 (4.993)33.1 (5.528)34.5 (5.762)39.6 (6.613)29.7 (4.960)18.0 (3.060)11.3 (1.887)11.2 (1.870)10.0 (1.670)GFRml min ^-1 1.73m ^-2—56.7350.4229.2221.02————————Serum proteing L ^-145.354.349.047.948.225.946.050.849.850.351.450.455.3Haemostatic therapy—2000 IU PPSB, 10 mg vitamin K 5 mg Idarucizumab, (∼27.8 IU kg^-1)————————LMWHLMWHLMWHIntervention—————Volume, furosemide—Start of CiCaCVVHDCiCaCVVHDCiCaCVVHDCiCaCVVHDCiCaCVVHDCiCaCVVHD

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