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Dabigatran — neurosurgical anathema?

To the Editor: We welcome the articles by Eikelboom and Hankey1 and Attia and Pearce2 about the use of dabigatran as an alternative to warfarin for prevention of embolic stroke. While it is encouraging that new, effective, anticoagulant agents have been added to the anticoagulant pharmacopoeia, we wish to raise specific concerns about the management of intracranial haemorrhage in patients treated with dabigatran.

While both the incidence and mortality of intracranial haemorrhage have been reported to be lower in patients taking dabigatran in the RE-LY trial, no mention was made as to operative management of such haematomas should they occur.3

Whereas emergent reversal of warfarin is possible and well standardised, no such evidence exists for dabigatran.4 With no rapid antidote, one suggested reversal strategy is haemodialysis for 3 hours to remove around 60% of the plasma levels of the drug.2 However, this is of little comfort to the neurosurgeon required to evacuate a life-threatening haematoma and control haemorrhage in a time-critical situation.