Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Isolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT—with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants—is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>In this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1–2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R<jats:sup>2</jats:sup> = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R<jats:sup>2</jats:sup> = 0.466). OAT itself was not an independent predictor for worse outcome.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>An OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.</jats:p></jats:sec>

The clinical relevance of ABO blood type in 100 patients with acute subdural hematoma

“…However, aSDH is a serious condition with high morbidity and mortality rates, especially among the elderly. [ 23 , 24 ] As the population ages, the prevalence of aSDH and patients with anticoagulation therapy is anticipated to identify the need for individualized hemostaseologic therapy, reliable risk and prognostic factors. [ 23 , 24 ]…”

Diagnosis and management of subdural hematoma: a review of recent literature

“…This score takes several factors into consideration including the use of anticoagulation drugs, the need for surgery, the presence of seizures history, along with other factors. 23 In conclusion, continuous research on anti-seizures drugs and their use in subdural hematoma is still required to establish their use for different presentations and scenarios.…”

Emergency Management of Subdural Hematoma

“…A recent research found that the risk of developing subdural hematoma can be up to 40 times more in individuals on anticoagulants than individuals who are not. Another Swiss study reported that up to 40% of patients with chronic subdural hematoma are on a daily anticoagulants regimen [9] .…”

“…When these patients present with a chronic subdural hematoma, the first step is to stop the antiplatelets therapy allowing for a proper neurosurgical management. After proper management is performed, the reintroduction of drugs can be considered with careful considerations [9] .…”