What is the management of a subdural hematoma on Brilinta (ticagrelor)?

From the Guidelines

Management of a subdural hematoma on Brilinta (ticagrelor) involves careful consideration of the risks and benefits of anticoagulation therapy. The patient should be immediately evaluated for any signs of increased intracranial pressure or neurological deterioration, and imaging studies such as CT scans should be performed to assess the size and location of the hematoma 1.

Key Considerations

• Reversal of anticoagulation: There is no clear evidence on how to reverse ticagrelor, but platelet transfusion may be considered in life-threatening bleeding 1.
• Risk of recurrent hemorrhage: The risk of recurrent hemorrhage must be weighed against the risk of an ischemic cerebrovascular event, and the decision to restart anticoagulation should be made on a case-by-case basis 1.
• Monitoring: Close monitoring of the patient's neurological status and repeat imaging studies should be performed to assess for any signs of hematoma expansion or new bleeding 1.

Treatment Options

• Surgical intervention: May be necessary in cases of significant hematoma expansion or increased intracranial pressure, and the type of surgery may vary depending on the location and size of the hematoma 1.
• Medical management: May include platelet transfusion, desmopressin, or other medications to reverse the effects of ticagrelor, as well as close monitoring of the patient's neurological status and repeat imaging studies 1.

Important Factors to Consider

• Type of hemorrhage: The type of hemorrhage, such as subdural or intracerebral, may affect the management and outcome of the patient 1.
• Patient age and comorbidities: The patient's age and comorbidities, such as atrial fibrillation or mechanical heart valve, may affect the decision to restart anticoagulation therapy 1.
• Risk factors for recurrent hemorrhage: The presence of risk factors such as advanced age, hypertension, or microbleeds on MRI may affect the decision to restart anticoagulation therapy 1.

From the Research

Management of Subdural Hematoma

The management of subdural hematoma, particularly in patients on Brilinta (ticagrelor), involves several approaches, including surgical evacuation and medical management.

• Surgical evacuation is often necessary for patients with acute subdural hematoma, with the goal of decompressing neural tissue and restoring perfusion 2.
• The choice of surgical technique depends on various factors, including the size and location of the hematoma, as well as the patient's overall health status 3.
• For patients on anticoagulant or antiaggregant therapy, such as Brilinta, the management of subdural hematoma may be more complex, and the decision to reverse anticoagulation or continue with surgical evacuation must be made on a case-by-case basis 2.

Surgical Techniques

Several surgical techniques are available for the management of subdural hematoma, including:

• Burr-hole craniostomy, which is a minimally invasive procedure that involves drilling a small hole in the skull to evacuate the hematoma 3.
• Craniotomy, which is a more invasive procedure that involves removing a portion of the skull to access the hematoma 4.
• Decompressive craniectomy, which is a procedure that involves removing a portion of the skull to allow the brain to expand and relieve pressure 4.

Medical Management

Medical management of subdural hematoma may include:

• Reversal of anticoagulation, if the patient is on anticoagulant or antiaggregant therapy 2.
• Management of blood pressure and intracranial pressure to prevent further bleeding or brain injury 5.
• Monitoring for signs of neurological deterioration, such as changes in mental status or focal neurological deficits 5.

Specific Considerations for Brilinta (Ticagrelor)

There is limited evidence specifically addressing the management of subdural hematoma in patients on Brilinta (ticagrelor). However, the general principles of managing subdural hematoma, including surgical evacuation and medical management, still apply 2. The decision to reverse anticoagulation or continue with surgical evacuation must be made on a case-by-case basis, taking into account the patient's overall health status and the risk of further bleeding or brain injury 2.