Utilization of Recombinant Activated Factor VII for Intracranial Hematoma Evacuation in Coagulopathic Nonhemophilic Neurosurgical Patients with Normal International Normalized Ratios

 

Shearwood McClelland III M.D., Eun Kyung Won M.D., Cornelius H. Lam M.D.

 

Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN

 

Introduction:

Recombinant activated Factor VII (rFVIIa) has recently gained popularity for rapid reversal of coagulopathy during operative neurosurgery. Patients undergoing chronic subdural hematoma (CSDH) or epidural hematoma (EDH) evacuation often have their coagulation status judged by preoperative international normalized ratio (INR) values. We present our experience in two patients with significant clinical coagulopathy who were successfully reversed with rFVIIa in the setting of normal INR.

 

Methods:

Patient one was a 79-year-old man with history of prostate cancer and three previous operative left CSDH evacuations, each complicated by coagulopathic bleeding in the operating room, who presented with new-onset left EDH. The second patient was a 27-year-old woman with relapsed acute myelogenous leukemia who presented for bone marrow transplant with a two-week history of worsening headache and photophobia following a lumbar puncture. MRI revealed bilateral CSDH with mass effect and effacement of the suprasellar and basal cisterns. Neither patient had hemophilia, and preoperative INR was 1.2 in each case. Both patients underwent urgent evacuation in the operating room, preceded by administration of rFVIIa.

 

Results:

Patient one underwent removal of his previous craniotomy flap followed by EDH evacuation. In patient two, coagulopathic bleeding upon skin incision necessitated an additional dose of rFVIIa in the operating room. Burrhole evacuation was well-tolerated with visible brain re-expansion following irrigation. Each case occurred with minimal blood loss and relatively easy hemostasis, with postoperative CT and neurological examination revealing adequate evacuation. Neither patient experienced thromboembolic complications or required re-operation.

 

Conclusion:

This series is the first to examine the use of rFVIIa for reversal of clinical coagulopathy in the setting of a normal INR. Our experience suggests that normal INR should not be a deterrent for nonhemophilic patients to receive rFVIIa in the setting of strong neurosurgical suspicion for underlying clinical coagulopathy, particularly in patients with known extracranial malignancy.

 

Keywords:

Recombinant Activated Factor VII, International Normalized Ratio, Chronic Subdural Hematoma, Epidural Hematoma, Nonhemophilic

 

Objectives:

1.    Understand the role of recombinant activated Factor VII (rFVIIa) in nonhemophilic neurosurgical patients

2.    Understand the impact of rFVIIa on reversing clinical coagulopathy in neurosurgical patients with a normal international normalized ratio (INR)

3.    Understand the potential link between extracranial malignancy and clinical coagulopathy requiring rFVIIa in neurosurgical patients with a normal INR

 

References:

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2.    Hartmann M, Sucker C, Messing M. Recombinant activated factor VII in the treatment of near-fatal bleeding during pediatric brain tumor surgery. Report of two cases and review of the literature. J Neurosurg. 2006;104(1 Suppl):55-58.

3.    Roitberg B, Emechebe-Kennedy O, Amin-Hanjani S, Mucksavage J, Tesoro E. Human recombinant factor VII for emergency reversal of coagulopathy in neurosurgical patients: a retrospective comparative study. Neurosurgery. 2005;57:832-836.