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Management of chronic subdural hematoma in patients treated with anticoagulation
A Zingale1, S Chibbaro, A Florio
1Divisione Clinicizzata di Neurichirurgia, Ospedale Garibaldi, Catania, Italy.
Insights
Patients on anticoagulation therapy who develop chronic subdural hematoma (CSDH) require prompt management. This includes correcting coagulopathy, appropriate surgical intervention, and careful management of anticoagulation to improve outcomes.
Area of Science:
- Neurosurgery
- Hematology
- Critical Care Medicine
Background:
- Increased use of metallic prostheses and bypass grafts necessitates long-term oral anticoagulation.
- Anticoagulation therapy is associated with an increased risk of chronic subdural hematoma (CSDH).
- Advancements in CT imaging allow for earlier diagnosis of CSDH.
Purpose of the Study:
- To evaluate the management and outcomes of patients with CSDH on anticoagulation.
- To propose guidelines for the optimal management of this patient subgroup.
Main Methods:
- Retrospective review of seven patients with CSDH on anticoagulation.
- Surgical intervention included subtemporal craniectomy or burr holes with closed drainage.
- Hypocoagulability was corrected with Vitamin K, fresh frozen plasma, and calcium heparin.
Main Results:
- Overall good outcomes were observed in most patients.
- One patient died due to cerebral herniation during extracorporeal dialysis.
- Complications included intracerebral hemorrhage, re-operation, and cerebral embolism. Mean hospital stay was 18 days.
Conclusions:
- Immediate correction of hypocoagulability is crucial.
- Appropriate surgical techniques and cautious management of anticoagulation conversion are recommended.
- Proposed guidelines aim to optimize the care of CSDH patients on anticoagulation.
Background:
The diffusion of the surgical technique of cardiac valve replacement with metallic prostheses, as well as bypass graft in the arterial occlusive disease of the lower extremities, both requiring permanent oral anticoagulation, has increased the number of patients affected by chronic subdural hematoma that can be diagnosed at an earlier stage of this disease with the advent of the CT.
Methods:
The records of seven patients with mean GCS = 14.2 and mean clinical grade = 1.85 affected by chronic subdural hematoma and in treatment with anticoagulants were examined retrospectively. All the patients underwent subtemporal craniectomy plus closed drainage or burrhole(s) plus closed drainage after immediate correction of hypocoagulability by administration of vitamin K and fresh frozen plasma and normalization of PA by calcium heparin.
Results:
Outcome was good for all the patients except one who died because of cerebral herniation due to massive solid subdural hematoma during extracorporeal dialysis. Complications included: intracerebral hemorrhage, solid subdural hematoma, slow brain reexpansion, subdural collection reaccumulation and cerebral embolism. Three patients required re-operation. Mean duration of hospital stay was 18 days with range from 7 to 24 days.
Conclusions:
Basing on this retrospective study and the proposed pathophysiology, the guidelines for optimal management of this subgroup of patients are proposed. Recommendations include the immediate correction of hypocoagulability, the appropriate surgical technique and the cautious conversion to oral anticoagulation as well as the appropriate timing of such conversion.