Intracranial hemorrhage associated with direct oral anticoagulant developing at three days after clipping for unruptured cerebral aneurysm through craniotomy

Abstract

We describe a case of a patient who developed an intracranial hemorrhage associated with direct oral anticoagulant (DOAC) after clipping for an unruptured aneurysm through craniotomy. A 65-year-old man with the administration of DOAC (Apixaban 10 mg/day) for embolic cerebral infarction underwent neck clipping for an unruptured left middle cerebral artery aneurysm. Three days before surgery, DOAC was stopped and heparin as 12,000 units/day was administrated intravenously. During surgery, a thin, pial artery bled slightly, and hemostasis was easily archived using cotton. Computed tomography (CT) immediately and 19 hours after surgery showed no evident intracranial hemorrhage. The patient received heparin as 12,000 units/day, and 10 hours later, heparin-DOAC bridge was started. Fourteen hours later, administration of heparin was stopped. Twenty-four hour later, he suffered sudden onset aphasia and CT showed a subdural hematoma and subarachnoid hemorrhage in the left Sylvian fissure. After discontinuance of DOAC, this symptom gradually resolved.