Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma

OBJECTIVE

Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics.

METHODS

Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes.

RESULTS

Of 138 patients who met inclusion criteria, 13.0% (n = 18) reported taking anticoagulants, 16.7% (n = 23) reported taking antiplatelets, and 3.6% (n = 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P = 0.040) and higher rates of palliative care consultations (P = 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group.

CONCLUSIONS

Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.

Rapid disappearance of acute subdural hematoma due to abrogated hyper-fibrinolytic activity by tranexamic acid: Case report

RATIONALE

Acute subdural hematoma (ASDH) occurs after tearing of bridging veins within the dura resulting in the accumulation of blood between the arachnoid and dura layers within 72 hours after traumatic head injury. Also, antigen fibrin D-dimer (DD) is the principal enzymatic degradation product of cross-linked fibrin by plasmin. We observed that early tranexamic acid (TXA) treatment resolved hyper-fibrinolysis and rapid disappearance ASDH.

PATIENTS CONCERNS

A 48-year-old female presented with unconsciousness for 2 hours after head trauma. Her Glasgow Coma Scale score was >8 points.

DIAGNOSIS

Computed tomography scan established ASDH with midline shift and brainstem compression and surgery was scheduled. Also, laboratory results indicated high DD spike of 34,820 μg/L and a reduction in plasma fibrinogen 1 hour after the injury.

INTERVENTION

She was treated with intravenous TXA immediately after admission.

OUTCOMES

Her DD spike decreased remarkably in 48 hours with associated rapid disappearance of ASDH thereby averting surgical intervention. She recovered fully with no long-term complications.

LESSONS

Historically, hyper-fibrinolysis is associated with poor outcome in head trauma. However, early initiation of TXA which is noninvasive treatment modality for ASDH could avert surgery and reduce cost, anesthesia, and other complications associated with surgery.

Recombinant activated factor VII for a warfarinised Jehovah’s Witness with an acute subdural haematoma

Recombinant activated factor VII (rFVIIa) (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) is a haemostatic agent first developed for bleeding associated with haemophilia and trauma, but for which the indications continue to expand. Recent reports have suggested efficacy for various types of intracranial haemorrhage and for patients with abnormalities of coagulation. We report a warfarin-anticoagulated Jehovah's Witness patient with an acute subdural haematoma for whom rFVIIa was used perioperatively. The haematoma was surgically evacuated without excessive blood loss and the patient eventually made a good recovery, returning to independent self-care.

Acute Subdural Hematoma: New Model Delineation and Effects of Coagulation Inhibitors

OBJECTIVE

To develop a highly reproducible rat model and behavioral tests for acute subdural hematoma (ASDH) and to investigate the role of intravascular coagulation and thrombin in the pathogenesis of brain injury in this model.

METHODS

A new method was implemented to inject 200 microl of autologous blood subdurally in rats. Immunohistochemistry was used to investigate intravascular fibrin deposition and thrombin levels in the cortex underlying the ASDH. Effectiveness of systemic heparin, argatroban, or ginkgolide B treatment was determined by histological lesion volume, number of occluded microvessels, and neurological deficits. Neurological deficits were monitored for 7 days after ASDH by use of forelimb placing, forelimb use asymmetry, and corner turn tests.

RESULTS

Consistent brain damage and sensorimotor deficits were observed in all animals with ASDH. Histological analysis demonstrated occluded microvessels and enlarged perivascular spaces in the underlying cortex starting 1 hour after hematoma induction. Fibrin and thrombin immunoreactivity were increased in the lesioned cortical parenchyma at 4 and 24 hours. However, no intravascular fibrin deposition was detected. Heparin induced hemorrhagic transformation in the cortical lesion and did not attenuate microvessel occlusion. Argatroban and ginkgolide B did not induce hemorrhage but failed to improve microvessel occlusion, lesion volume, and neurological deficits.

CONCLUSION

Intravascular coagulation and thrombin are not the major mediators of brain damage after ASDH. The model and behavioral tests presented in this study can be used to investigate other putative mechanisms of injury and to test future therapeutic interventions in ASDH.

Tempol, a novel stable nitroxide, reduces brain damage and free radical production, after acute subdural hematoma in the rat

Recent studies have shown that there is increased production of deleterious free radicals following acute subdural hematoma (ASDH). Scavenging them may therefore be of therapeutic benefit. Nitroxides are new, low molecular weight, cell permeable superoxide dismutase mimics. This study investigated the neuroprotective effect of 4-hydroxy-2,2,6,6-tetramethylpiperidine-1-oxyl (Tempol) following ASDH in the rat. Twenty-one male Sprague-Dawley rats were used in two studies: (1) a volumetric study of ischemic brain damage (n = 10); and (2) a microdialysis study measuring free radical generation after ASDH (n = 11). Ten minutes after induction of hematoma, the animals received 10 mg/kg Tempol or vehicle intravenously. In the volumetric study, 4 h after treatment, the rats were perfused, the brain removed, cut into serial 12-microm coronal sections, and stained. Ischemic areas were measured in eight predetermined stereotactic planes. In the microdialysis study, free radical production was measured using the salicylate trapping technique by quantifying 2,3-dihydrobenzoic acid (2,3-DHBA) and 2,5-DHBA using HPLC. In the volumetric study, Tempol treatment significantly reduced infarct volumes; 100.2 +/- 15.7 mm3 in Tempol-treated animals compared with 171.5 +/- 13.6 mm3 in controls (42% reduction, p = 0.0005). The microdialysis study demonstrated an early twofold increase of free radical production at 30 min, and returning to the baseline levels in controls. However, in Tempol-treated animals, this early surge was attenuated, and all measured values remained around the baseline levels throughout the experiments. Tempol thus provides significant neuroprotective effect in a rat model of ASDH, related to attenuation of superoxide radical production. The use of these low molecular weight, cell-permeable agents, which readily cross the blood-brain barrier and enter cells, thus appears indicated for acute pathologies, ASDH.

Recombinant coagulation factor VIIa for rapid preoperative correction of warfarin-related coagulopathy in patients with acute subdural hematoma

BACKGROUND

Intracranial hemorrhage, either spontaneous or traumatic is a well-known and potentially lethal complication of Warfarin treatment. Patients with Warfarin-related intracranial hemorrhage need urgent reversal of anticoagulation that must be especially rapid if surgical intervention is indicated. The traditional treatment with fresh frozen plasma (FFP) and vitamin K often fails to achieve the desired correction of coagulopathy in urgent neurosurgical settings.

CASE REPORT

In the present case Recombinant Coagulation Factor VIIa (rFVIIa) was used for preoperative reversal of Warfarin-related coagulopathy. The patient was a fifty two years old man, mechanic valve recipient with Warfarin-induced coagulopathy: International Normalization Ratio (INR) of 6.39, who suffered from acute subdural hematoma and needed urgent neurosurgical intervention. He received a single dose of rFVIIa 120 mg/kg and immediately underwent craniotomy and evacuation of the hematoma. Appropriate hemostasis was achieved during surgery and coagulation test taken two hours after rFVIIa injection revealed INR of 1.25. The INR remained normalized for additional 14 hours. To the best of our knowledge, this is the first report on the use of rFVIIa in the preoperative management of Warfarin-induced intracranial hemorrhage.

RESULTS

Recombinant Coagulation Factor VIIa provides rapid correction of coagulation to a level that allows safe neurosurgical intervention without significant delay. This agent is safe and effective; and should be considered for reversal of Warfarin-induced coagulopathy in cases of intracranial hemorrhage, especially when urgent surgical intervention is required.

Chemical shift imaging of mannitol in acute cerebral ischemia. Case report

The effectiveness of mannitol for the treatment of cerebral edema after stroke has long been debated, and the diffusion of mannitol through a disrupted blood-brain barrier has been the focus of many contradictory studies. The authors present a unique case in which chemical shift imaging was used to demonstrate the accumulation of mannitol in an area of stroke underlying a subdural hematoma in a patient with end-stage renal disease being treated with hemodialysis. A metabolite map for the xenobiotic mannitol was created from the data and demonstrated the accumulation of mannitol when hemodialysis was interrupted prematurely. Metabolite maps were also used to show removal of the mannitol with the reestablishment of hemodialysis. It is concluded that mannitol can accumulate in an area of infarction, and that chemical shift imaging can be used to illustrate this process.

Effects of mild hypothermia and alkalizing agents on brain injuries in rats with acute subdural hematomas

Brain ischemia is the leading pathopysiological mechanism in the development of secondary brain damage after acute subdural hematoma (SDH). Hypothermia has been employed as an effective cerebroprotective treatment on brain injuries, but the control of the general condition is very difficult under hypothermia, and various severe complications have been reported. Cerebral acidosis in the ischemic area is one of the important factors augmenting the brain edema formation. Tris-(hydroxymethyl)-aminomethane (THAM) has been used as an alkalizing agent for acidosis on brain injury and is reported to be effective. In the present study, we used a rat acute SDH model to assess the effect of mild (35 degrees C) hypothermia and THAM combined treatment on brain water content, brain ischemia, and blood-brain barrier (BBB) permeability at 4 h after hematoma induction. Mild hypothermia did not significantly reduce the brain water content beneath the hematoma (79.5 +/- 0.2%) compared to normothermia (80.2 +/- 0.2%), but mild hypothermia combined to THAM resulted in a significant reduction (78.7 +/- 0.0%; p < 0.01). Combined with mild hypothermia, THAM treatment significantly reduced the Evan's blue extravasation (35 +/- 7 ng/g wet tissue; p < 0.05) compared to normothermia (63 +/- 7 ng/g wet tissue). Furthermore, the volume of infarction at 24 h after the hematoma induction (54 +/- 3 mm(3); p < 0.01) was significantly smaller by the combined treatment compared with normothermia (70 +/- 2 mm(3)). The present findings indicate that mild hypothermia of 35 degrees C combined with THAM presents a potent cerebroprotective strategy. The protection of the BBB is one of the possible cerebroprotective mechanisms in this rat acute SDH model.

Nonsurgical treatment of an upper thoracic spinal subdural hemorrhage

STUDY DESIGN

A case report of an upper thoracic spinal subdural hemorrhage which was managed successfully by conservative treatment.

OBJECTIVES

Spinal subdural hemorrhage is rare and can cause serious neurologic symptoms. Surgery is the most common treatment and is believed to prevent further neurologic injury. A case of an upper thoracic spinal subdural hemorrhage which was managed successfully by conservative therapy is reported.

SETTING

Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Japan.

METHODS

A 29-year-old woman presented with acute severe back pain. She experienced acutely developed weakness of both lower extremities, hypesthesia below T6 and urinary retention. Magnetic resonance imaging performed on the day of hospital admission revealed the existence of a subdural hematoma in the upper thoracic spine. Muscle strength of the lower extremities was grade 0 on admission, but improved slightly on day 1. The decision was made to manage the patient nonoperatively by corticosteroid and diuretic administration.

RESULTS

Improvement was gradual but progressive. Muscle strength was grade 4 out of 5 on the 28th day. Magnetic resonance imaging at 3 months except for mild urinary retention.

CONCLUSIONS

Spinal subdural hemorrhage can be treated nonoperatively by correlating magnetic resonance image findings with the clinical condition.