Poor outcomes after dabigatran-associated intracranial hemorrhage despite idarucizumab reversal

Abstract

Intracranial hemorrhage (ICH) is the most deadly bleeding complication associated with anticoagulation. The efficacy of idarucizumab in treating dabigatran-associated ICH in the real world is uncertain. We sought to assess patient outcomes in this sick population. This was a 2-year prospective observational study of functional neurologic status in patients who received idarucizumab following dabigatran-associated ICH across three tertiary Canadian hospitals. The primary outcome was disability on the modified Rankin scale thirty days after antidote administration. Five patients received idarucizumab for dabigatran-associated ICH. The median time to idarucizumab administration was 43 minutes (range: 2-163 minutes). Four patients were dead at 30 days. The fifth patient was in a minimally conscious state with hemiparesis requiring full nursing care. Three patients were transitioned to palliative care based on their advanced directives and dismal prognosis as determined by the treating team. High quality care should not include idarucizumab when it is unlikely to achieve patients' previously stated goals of care. However, rapid administration of this expensive antidote is often necessary when information is incomplete.