Abstract Number: PB0065
Meeting: ISTH 2021 Congress
Background: Deficiency of Antithrombin (AT) represents a risk factor for thromboembolic disease. However, there is considerable variation in its expression and the management of anticoagulant therapy can be challenging. In contrast, cerebral arteriovenous malformations (AVMs) are relatively uncommon but an important cause of intracranial hemorrhage (ICH).
Aims: To present a case report of a patient with AT deficiency, under anticoagulation, with an ICH due to AVM.
Methods: We report a case of a 40-year-old male with deficiency of AT and history of recurrent deep vein thrombosis under rivaroxaban 20 mg/day. The patient was admitted to the emergency department due to an ICH associated with an AVM.
Results: When indicated, we use prothrombin complex concentrates (PCC) to reverse anticoagulation in patients under rivaroxaban, as andexanet alfa is not available. As rivaroxaban concentration was < 25 ng/mL, it was decided not to use PCC. After a hemorrhagic event, the approach involves managing the thrombotic and bleeding recurrence risk. This patient, after embolization, developed hemorrhagic coagulopathy needing transfusion support (fresh frozen plasma and fibrinogen concentrate), as he had a large femoral hematoma when the catheter was removed. This coagulopathy was assumed to be related to contrast extravasation as he had an iatrogenic femoral pseudoaneurysm, whereby deferring the anticoagulation resumption. When resuming anticoagulation in this patient, unfractionated heparin will be used and AT replacement may be necessary to enhance heparin anticoagulant efficacy. Alternatively, a parenteral direct thrombin inhibitor such as argatroban, which does not require AT function, may be used.
Conclusions: Deficiency of AT, after a hemorrhagic event, may represent a huge challenge to restart anticoagulation. The balance of coagulation is not linear and decisions regarding therapy are individualized depending on the specific status of the patient. Depending on the circumstances, the hemorrhagic or the thrombotic risk prevails.
To cite this abstract in AMA style:Machado I, Teixeira S, Cibele Gonçalves D, Monteiro C, Carvalho M, Ricca Gonçalves L, Neves C, Koch MdC. The Coagulation Balance: Intracranial Hemorrhage in a Patient with Antithrombin Deficiency. A Case Report [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/the-coagulation-balance-intracranial-hemorrhage-in-a-patient-with-antithrombin-deficiency-a-case-report/. Accessed November 29, 2023.
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