Heparin

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An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 60-year-old man developed non-traumatic, simple type acute subdural haematoma (ASDH) with brain herniation, epistaxis and blood leakage from the ECMO cannulation site during treatment with heparin for anticoagulant therapy.

The man, who had COVID-19, was transferred to the emergency department of hospital. He was non-smoker and had a history of hypertension. HIs concomitant medication included telmisartan. On day 8, extracorporeal membrane oxygenation (ECMO) was introduced, and he started receiving continuous heparin [route not stated] on day 12. Following the administration of heparin 37200 units/day, D-dimer showed a propensity for hypercoagulability, and thrombi floating in the circuit were noted. On admission day 15, he needed a circuit replacement to avoid embolism and circuit obstruction. Subsequently, blood leakage from the ECMO cannulation site and epistaxis occurred. The ECMO was detached in a state, and ECMO management persisted as a filter to eliminate intravascular thrombus. The target activated coagulation time (ACT) value was elevated to 200 to 260 seconds to avoid blood clots in the circuit. Therefore, dose of heparin was slowly increased. On day 26 at 2:10am, anisocoria was noted. During that time, his activated partial thromboplastin time (APTT) was ≥200 seconds and ACT was 253 seconds. Heparin stock solution (5,000 units/5mL), which was continuously given with a daily dose of 72000 units at a rate of 3 mL/h, was stopped at 3 o'clock and ACT decreased at 4 o'clock. A head CT was carried out at 05:09am that revealed left ASDH with a 10mm midline shift. There was no skull fracture or brain contusion suspected of trauma. A CT angiography showed dural arteriovenous fistula and cerebral aneurysm. Since, he needed ECMO, he had analgesia and deep sedation with a Glasgow coma scale (GCS) of E1VTM1. It was decided to remove the haematoma since it was a simple haematoma type. Before the surgery, to avoid the reduction of ECMO function because of blood clots, protamine sulfate [protamine] was given after substituting the artificial membrane type lung, and ACT was maintained at 157 seconds. Additionally, the haematoma of the frontotemporal fornices that was strongly involved in the umbilical hernia formed Niveau, that was likely to be a liquid haematoma which was expected to be easily removed. A small incision was made in the dura mater, and a liquid hematoma occurred rapidly, and intracranial pressure elevated. A a red-violet solid acute subdural haematoma just below the superior temporal line was removed. Drains were introduced in each direction under the dura mater, and the haematoma was irradiated. Subsequently, intracranial pressure sensor and drain were kept while noticing the subdural space with a brain vera with a light pressure. Since the brain was bulging, the bony valve was not reverted with minimal dural suture, and the wound was shut. After returning to the room, the intracranial pressure became normal. It was reported that ASDH with brain herniation, epistaxis and blood leakage from the ECMO cannulation site were considered to be secondary to heparin [durations of treatment to reactions onset not stated]. Heparin was stopped as scheduled following the surgery, and ECMO management persisted. Thrombus in the artificial membrane type lung was established, and it was essential to carry out circuit replacement on day 30; however, ECMO was weaned on day 33, and the intracranial pressure became normal. Since the intracranial pressure was stable, CT was carried out after 3 days of the surgery. Following the reduction of mass effect, the subdural drain was removed. Intracranial pressure sensor was removed 8 days after the surgery. He was tested negative for COVID-19. Thereafter, gastrostomy and tracheostomy were carried out on day 41, and he was weaned from the ventilator on day 49. On day 71, he was transferred with modified Rankin Scale (mRS) score of 4 to the convalescent rehabilitation where mRS score improved to 3 after 90 days of the surgery [not all outcomes stated].