What is the best treatment approach for a 75-year-old patient with a history of hypertension, diabetes, and cardiovascular disease, currently taking antihypertensives, anticoagulants, and antiplatelet agents, who has been diagnosed with intraparenchymal hemorrhage (IPH) and subdural hematoma (SDH), presenting with unstable vital signs?

Management of IPH and SDH in a 75-Year-Old on Anticoagulants and Antiplatelets

Immediately discontinue all anticoagulants and antiplatelet agents and reverse anticoagulation as rapidly as possible to prevent hematoma expansion, which is the only modifiable predictor of mortality in intracranial hemorrhage. 1

Immediate Anticoagulation Reversal

The priority is rapid reversal of anticoagulation within minutes, not hours, as 30-40% of intracranial hemorrhages expand within the first 12-36 hours. 1

For Vitamin K Antagonists (Warfarin)

• Administer 4-factor prothrombin complex concentrate (4F-PCC) immediately if INR ≥2.0, which normalizes INR within 15 minutes 1
• Give intravenous vitamin K immediately after 4F-PCC to prevent re-emergence of anticoagulation 1
• Use fresh frozen plasma (FFP) or 3-factor PCC only if 4F-PCC is unavailable 1

For Direct Oral Anticoagulants (DOACs)

• Administer idarucizumab for dabigatran reversal 1
• Give andexanet alpha for factor Xa inhibitors (apixaban, rivaroxaban, edoxaban); if unavailable, use 4F-PCC 1
• Consider hemodialysis for dabigatran removal if antidote unavailable 1

For Heparin

• Administer intravenous protamine sulfate immediately 1

For Antiplatelet Agents

• Do NOT administer platelet transfusions—randomized trial data demonstrate worse outcomes in ICH patients receiving antiplatelet therapy who are treated with platelet infusion 1
• Discontinue aspirin, clopidogrel, ticagrelor, and prasugrel immediately 1

Blood Pressure Management

Target systolic blood pressure of 130-150 mmHg (specifically 140 mmHg) within 6 hours of symptom onset to reduce hematoma expansion risk. 1

• Use rapid-onset, short-duration antihypertensive agents to facilitate precise titration 1
• Strictly avoid systolic blood pressure <110 mmHg, as very intense blood pressure lowering below 130 mmHg is potentially harmful 1
• Maintain blood pressure below 180/105 mmHg after the acute phase 1

Neurosurgical Evaluation

Obtain immediate neurosurgery consultation for assessment of need for emergent surgical intervention based on mass effect, edema, and rate of hematoma expansion. 1

Indications for Surgical Intervention

• Significant mass effect causing midline shift 2
• Intraventricular hemorrhage with hydrocephalus contributing to decreased consciousness requires external ventricular drainage 1
• Progressive neurological deterioration despite medical management 3, 2
• Large hematoma volume (>30 mL for supratentorial, >10 mL for infratentorial) 2

Surgical Considerations in Elderly Patients

• Preoperatively independent patients without antithrombotic medication have 1-year mortality of 30%, compared to 56% for those on antithrombotics and 69% for dependent patients 4
• All patients with Glasgow Coma Scale 3-8 who are on antithrombotics or functionally dependent have 100% 1-year mortality 4
• Surgery promotes equivalent neurologic outcomes without increased recurrence or reoperation rates compared to younger patients 5

Diagnostic Imaging

Obtain non-contrast CT head immediately to assess hematoma size, location, mass effect, and midline shift. 1

Additional Vascular Imaging

• Perform CTA with venography in this 75-year-old with lobar IPH to exclude macrovascular causes or cerebral venous thrombosis, as hypertensive hemorrhage is most common but other etiologies require specific interventions 1
• Consider catheter angiography if CTA/MRA are negative but clinical suspicion remains for vascular malformation, as 11% of cases with negative non-invasive imaging have arteriovenous malformations or dural arteriovenous fistulas on catheter angiography 1

Critical Monitoring

Admit to intensive care unit or stroke unit with continuous cardiac monitoring for at least 24 hours to detect arrhythmias and monitor for neurological deterioration. 1

• Repeat head CT at 6-12 hours to assess for hematoma expansion 2
• Monitor for signs of increased intracranial pressure: altered mental status, pupillary changes, Cushing's triad 3
• Watch for seizures, which occur in 22% of IPH cases 1

Anticoagulation Resumption Considerations

The decision to restart anticoagulation requires weighing the 25% mortality risk from post-evacuation IPH against thromboembolic risk from cardiovascular disease. 1, 2

• Duration of anticoagulation interruption in high-risk cardiovascular patients is unknown and must be individualized based on bleeding versus thrombotic risk 1
• Patients with mechanical heart valves or atrial fibrillation face competing risks that require multidisciplinary consultation with neurology, neurosurgery, and cardiology 1
• Consider bridging strategies only after documented hematoma stability on serial imaging 1

Prognosis Factors

Mortality risk is substantially elevated by: age >75 years, anticoagulant/antiplatelet use, hypertension, ischemic heart disease, initial hematoma thickness >8.9 mm, and Glasgow Coma Scale <9. 2, 4, 6

• Patients surviving to 1 year have life expectancy comparable to age-matched peers 4
• Intraparenchymal hemorrhage after SDH evacuation carries 25% mortality 2
• Complete neurological recovery occurs in 81% of appropriately managed cases 1