We report a case of extensive cardiogenic cerebral infarction resulting in permanent disability arising from an interruption in oral anticoagulants before dental surgery. A 71-year-old woman with a history of atrial fibrillation and hypertension was scheduled to undergo an implant placement in the maxillary molar area. She had been taking warfarin (2 mg/day) to prevent thromboembolic events, and the dosage had been titrated to maintain an international normalized ratio of prothrombin time (PT-INR) of 1.7-2.1 for the last nine months. The patient was instructed not to take warfarin for four days before or on the day of surgery by her cardiologist, and warfarin was resumed on the day after surgery. On postoperative day three, she suffered a stroke and was admitted emergently. She presented with right hemiplegia and aphasia, and her Glasgow Coma Scale (GCS) score was 8 (E3V1M4). The PT-INR was 1.17 on admission, and brain magnetic resonance imaging showed an extensive hemorrhagic infarction in the territory of the left anterior and middle cerebral artery. Despite conservative treatment, the brain edema progressed and resulted in impending brain herniation requiring an emergent decompressive craniotomy, which was performed on the sixth day after admission. She was discharged to a nursing home with an improved GCS score of 11 (E4V2M6) but with residual dysphasia 50 days after admission. Recent professional guidelines recommend that anticoagulants not be discontinued in the most patients requiring dental extraction. Following such recommendations is crucial to prevent fatal thromboembolic events in patients receiving anticoagulants who require dental implants.
