Antithrombotic regimens and need for critical care interventions among patients with subdural hematomas.

BACKGROUND: Antithrombotic-associated subdural hematomas (SDHs) are increasingly common, and the possibility of clinical deterioration in otherwise stable antithrombotic-associated SDH patients may prompt unnecessary admissions to intensive care units. It is unknown whether all antithrombotic regimens are equally associated with the need for critical care interventions. We sought to compare the frequency of critical care interventions and poor functional outcomes among three cohorts of noncomatose SDH patients: patients on no antithrombotics, patients on anticoagulants, and patients on antiplatelets alone. METHODS: We performed a retrospective cohort study on all noncomatose SDH patients (Glasgow Coma Scale > 12) presenting to an academic health system in 2018. The three groups of patients were compared in terms of clinical course and functional outcome. Multivariable logistic regression was used to determine predictors of need for critical care interventions and poor functional outcome at hospital discharge. RESULTS: There were 281 eligible patients presenting with SDHs in 2018, with 126 (45%) patients on no antithrombotics, 106 (38%) patients on antiplatelet medications alone, and 49 (17%) patients on anticoagulants. Significant predictors of critical care interventions were coagulopathy (OR 5.1, P < 0.001), presence of contusions (OR 3, P = 0.007), midline shift (OR 3.4, P = 0.002), and maximum SDH thickness (OR 2.4, P = 0.002). Significant predictors of poor functional outcome were age (OR 1.8, P < 0.001), admission Glasgow Coma Scale score (OR 0.3, P < 0.001), dementia history (OR 4.2, P = 0.001), and coagulopathy (OR 3.5, P = 0.02). Isolated antiplatelet use was not associated with either critical care interventions or functional outcome. CONCLUSION: Isolated antiplatelet use is not a significant predictor of need for critical care interventions or poor functional outcome among SDH patients and should not be used as a criterion for triage to the intensive care unit.

Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively.

Acute subdural hematomas (ASDHs) are highly morbid and increasingly common. Hematoma expansion is a potentially fatal complication, and few studies have examined whether factors associated with hematoma expansion vary over time. To answer this, we performed a case-control study in a cohort of initially conservatively managed patients with ASDH. Two time periods were considered, early (<72 h from injury) and delayed (>72 h from injury). Cases were defined as patients who developed ASDH expansion in the appropriate period; controls were patients who had stable imaging. Associated factors were determined with logistic regression. We identified 68 cases and 237 controls in the early follow-up cohort. Early ASDH expansion was associated with coagulopathy (adjusted odds ratio [aOR] 2.3, 95 % CI: 1.2-4.5; p = 0.02), thicker ASDHs (aOR 1.1, 95% CI: 1.03-1.2; p = 0.006), additional intracranial lesions (aOR 3, 95% CI: 1.6-6.2; p = 0.002), no/minimal trauma history (aOR 0.4, 95% CI: 0.2-0.9; p = 0.03), and duration between injury and initial scan (aOR 0.9, 95% CI: 0.8-0.97; p = 0.04). In the delayed follow-up cohort, there were 41 cases and 126 controls. Delayed ASDH expansion was associated with older age (aOR 1.3 per 10 years, 95% CI: 1.1-1.6; p = 0.01), systolic blood pressure (SBP) >160 on hospital presentation (aOR 4.5, 95% CI: 1.8-11.3; p = 0.001), midline shift (aOR 1.5 per 1 mm, 95% CI: 1.3-1.9; p < 0.001), and convexity location (aOR 14.1, 95% CI: 2.6-265; p = 0.013). We conclude that early and delayed ASDH expansion are different processes with different associated factors, and that elevated SBP may be a modifiable risk factor of delayed expansion.

Mechanical Thrombectomy of Acute Middle Cerebral Artery Occlusion Using Trans-Anterior Communicating Artery Approach.

BACKGROUND: A cross-circulation technique involves gaining access to a cerebral vessel through a patent anterior or posterior communicating artery. This technique may be used in patients with emergent large-vessel occlusions and an unfavorable direct route to the occlusion. While few previous reports have demonstrated a successful cross-circulation technique for treatment of emergent large-vessel occlusions, we present the first 2 cases of transanterior communicating artery stent retriever thrombectomy. CASE DESCRIPTION: Case #1: A 64-year-old female presented with acute right middle cerebral artery (MCA) occlusion. She demonstrated a "triple-tandem" brachiocephalic-internal carotid artery-middle cerebral artery occlusion, thus precluding direct access to the right MCA. Successful stent retriever mechanical thrombectomy was performed across the anterior communicating artery, using a left internal carotid artery approach. Case #2: A 70-year old female presented with acute occlusion of the left MCA and tandem occlusion of the cervical left internal carotid artery. Multiple attempts to catheterize the left common carotid artery were unsuccessful. She underwent successful stent retriever mechanical thrombectomy across a patent anterior communicating artery, using a right internal carotid artery approach. CONCLUSIONS: Timely recanalization of an occluded artery plays a critical role in the prognosis of patients with acute ischemic stroke. Successful stent retriever mechanical thrombectomy of an occluded MCA is possible using a transanterior communicating artery approach in patients without a direct access route to the occluded intracranial vessel. We review the pathophysiology of tandem lesions, access routes to intracranial occlusions, and the literature on cross-circulation techniques to treat emergent large-vessel occlusions.