Background: Intracranial hemorrhage is a severe and possibly fatal consequence of anticoagulation therapy. Idarucizumab is used in dabigatran-treated patients suffering from intracranial hemorrhage (ICH) to reverse the anticoagulant effect of dabigatran. Systematic review of real-life mortality in these patients is missing. Objectives: A review of all published dabigatran-related ICH cases treated with idarucizumab was performed. We aimed to estimate in-hospital mortality rate in these patients. Method: We searched PubMed and Scopus for all published cases of ICH in idarucizumab/dabigatran-treated patients until May 15, 2021. The assessed outcome was in-hospital mortality. Results: We identified six eligible studies (case series) with 386 patients and 54 single case reports. In-hospital mortality rate was 11.4% in the case series and 9.7% in the case reports. Conclusions: Our analysis provides clinically relevant quantitative data regarding in-hospital mortality in idarucizumab/dabigatran-treated patients with ICH, which is estimated to be 9.7-11.4%.

We report the case of an 81-year-old man taking dabigatran etexilate (dabigatran) for chronic atrial fibrillation, who presented with acute-onset hemoptysis and hypoxia. Chest high-resolution computed tomography showed bilateral ground grass opacities. After admission, his respiratory failure progressed rapidly and bronchoalveolar lavage was performed immediately, which showed copious amounts of bloody fluid and hemosiderin-laden macrophages with Prussian blue staining. He was diagnosed as having diffuse alveolar hemorrhage (DAH). We therefore stopped dabigatran and initiated multimodality therapy including idarucizumab, which is a reversal agent for dabigatran. Clinical and radiological improvement was observed and he was discharged without any impairment. There has been no relapse of DAH since then. No abnormalities were detected on further investigation; finally, we concluded that his DAH was caused by dabigatran. This is the first known case of idarucizumab use for severe DAH caused by dabigatran. Our case suggested that dabigatran can cause life-threatening DAH; in such cases, administering idarucizumab could be an effective treatment option.