Anterior STEMI After Acute Subdural Hematoma: A Management Dilemma

Management of acute coronary syndrome in patients with a high bleeding risk requires careful clinical judgment to weigh the benefit of percutaneous intervention and subsequent antiplatelet pharmacotherapy with the risks of bleeding. A 70-year-old man developed anterior ST-segment elevation myocardial infarction 4 days after undergoing neurosurgical evacuation of subdural hematoma. After successful percutaneous intervention with plain-old balloon angioplasty, cangrelor was started owing to bleeding risk. The subdural hematoma remained stable during dual antiplatelet therapy (DAPT) therapy. In a patient who may not have been able to tolerate DAPT therapy, plain-old balloon angioplasty may be safer than deploying a stent to avoid stent thrombosis if DAPT is discontinued. Cangrelor is the only P2Y₁₂ inhibitor available in an intravenous form and can be quickly turned on/off for patients with a very high bleeding risk. A simultaneous acute subdural hematoma with ST-segment elevation myocardial infarction is uncommon and poses a management challenge. A tailored clinical approach that extends beyond the scope of current guidelines was warranted.