Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants.

BACKGROUND: Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited. METHODS: We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30 months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included. RESULTS: A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment. CONCLUSIONS: These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.

Acute Intracranial and Spinal Subdural Hematoma Associated with Vardenafil.

A 28-year-old healthy man was admitted to our hospital because of right-sided headache, vomiting, and lower back pain after the administration of vardenafil. Computed tomography and magnetic resonance imaging of the brain showed a small, right-sided, subdural hematoma. A lumbar magnetic resonance imaging showed a longitudinally extended subdural hematoma. He had no history of trauma. We speculated that vardenafil might have had an association with the bleeding. Several reports have suggested a relationship between phosphodiesterase-5 inhibitors and intracerebral or subarachnoid hemorrhage. Our case suggested that there may also be risks of bleeding into the subdural space. Although headache and nausea are common side effects of vardenafil, hemorrhagic diseases should also be considered when symptoms are severe or prolonged.

Case report of subdural hematoma in a patient with Sturge-Weber syndrome and literature review: questions and implications for therapy.

Sturge-Weber syndrome is a neurocutaneous disorder associated with vascular abnormalities in the skin, eye, and brain leading to both acute and chronic cerebral hypoperfusion and, in some affected children, brain injury. Aspirin can reduce stroke-like events and seizure episodes and prevent further brain injuries in these patients. Although a few cases of intracranial hemorrhage in patients with Sturge-Weber syndrome have been reported, prior reports have not discussed this complication with regard to particular therapies. The authors present a toddler with Sturge-Weber syndrome who developed a subdural hematoma in the setting of a mechanical fall with minor head trauma. They discuss the possible role of aspirin in contributing to, or perhaps protecting against, intracranial hemorrhage in patients with Sturge-Weber syndrome. Further data are needed to establish the utility of aspirin in Sturge-Weber syndrome.

Delayed subdural hematoma after receiving enoxaparin for prevention of thromboembolic events from high-risk surgery.

Enoxaparin (Lovenox) is a low­molecular weight heparin used to prevent deep venous thrombosis in patients undergoing total hip or knee arthroplasty. Anticoagulation in a patient after trauma may be dangerous and lead to significant hemorrhage. An elderly man fell and sustained a concussion and a hip fracture. His initial computed tomographic scan of the head was normal. He received enoxaparin perioperatively and developed a delayed extensive subdural hematoma. Although enoxaparin has been shown to be an effective and a safe drug for venous thromboembolism prophylaxis in orthopedic surgeries and trauma, severe bleeding may rarely occur, especially in the setting of head trauma. Other therapies for venous thromboembolic prophylaxis, such as mechanical thromboembolism prophylaxis methods, should be considered.

An Atropa belladonna L. poisoning with acute subdural hematoma.

Atropa belladonna L. is a plant long known to cause poisoning. But no cases of acute subdural hematoma resulting from such poisoning have been reported so far. Care must also be taken in terms of acute pancreatitis and rhabdomyolysis in cases of such poisoning. The plant may sometimes be mistaken for the Caucasian blueberry, V. arctostaphylos L. At least one anti-cholinesterase toxidrome finding was determined in all the nine cases of belladonna poisoning in this series. No elevated creatine kinase was reported in one case with acute subdural hematoma and hyperamylasemia.

Posterior fossa acute subdural haematoma following anticoagulant therapy. Case report.

A case of acute subdural haematoma of the posterior fossa in an alive adult secondary to anticoagulant therapy is described. The clinical presentation and the final decision of conservative management are discussed and the literature is reviewed.

Acute subdural hematoma after intra-arterial thrombolysis for acute ischemic stroke--case report.

A 79-year-old man with a cardiac pacemaker for bradycardia fell down and presented with sudden onset of right hemiplegia and aphasia. Initial computed tomography (CT) showed no cerebral infarction but angiography revealed occlusion of the left middle cerebral artery (MCA). Local intra-arterial thrombolysis with tissue plasminogen activator (tPA; tisokinase, 1,600,000 units) was performed 3 hours after the onset, and the MCA was partially recanalized. Further administration of tPA was suspended because of nosebleed. However, the patient's neurological findings did not improve. His consciousness gradually deteriorated to coma and quadriplegia with dilation of the left pupil 2.5 hours after thrombolysis. CT disclosed marked mass effect with a left acute subdural hematoma and a small intracerebral hematoma in the left frontal lobe. He underwent urgent craniotomy and removal of the subdural hematoma. The subdural hematoma originated in a frontal cerebral contusion. He died of severe brain edema 2 days after surgery. Acute subdural hematoma is a very rare complication of intra-arterial thrombolysis. Presumably he had suffered head trauma at the first onset. Evidence of head trauma should be considered a contraindication for the use of thrombolytic agents in a patient with acute stroke.

Cocaine-related acute subdural hematoma: an emergent cause of cerebrovascular accident.

A case of "spontaneous" acute subdural hematoma caused by cocaine abuse is described. As an isolated cerebrovascular event, related to cocaine abuse, this is the first report in the literature. It also represents a new differential diagnosis for nontraumatic acute subdural haematomas. The putative pathophysiology of the lesion is discussed.

Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device.

BACKGROUND AND OBJECTIVES: Complications related to cerebrospinal fluid (CSF) leak and low CSF pressure can occur following placement of an intrathecal drug delivery device. METHODS: A 58-year-old man with chronic, intractable lower back pain underwent implantation of an intrathecal drug delivery device. On the fourth postoperative day, he developed a postural headache and diplopia with findings compatible with left sixth cranial nerve palsy. The headache subsequently became constant and nonpostural. Cranial magnetic resonance imaging was obtained that showed the presence of a posterior subdural intracranial hematoma. Conservative treatment for postdural puncture headache did not improve the symptomatology. Therefore, an epidural blood patch was performed that produced rapid improvement and eventual resolution of symptoms. CONCLUSIONS: Intrathecal catheter implantation can result in CSF loss that might not resolve promptly with conservative therapy. In this case, epidural blood patch proved to be a safe and effective form of treatment.