What is the best management approach for a patient with a subdural hematoma, likely on anticoagulation therapy, undergoing Thromboelastography (TEG) testing?

Management of Subdural Hematoma in Anticoagulated Patients Undergoing TEG Testing

In a patient with subdural hematoma on anticoagulation undergoing TEG testing, immediately reverse anticoagulation with prothrombin complex concentrates (50 IU/kg) plus vitamin K (10 mg) or fresh frozen plasma if PCC unavailable, then use TEG parameters to guide targeted correction of specific coagulation defects before surgical intervention. 1, 2, 3

Immediate Reversal of Anticoagulation

Rapid normalization of coagulation is mandatory because 30-40% of subdural hematomas expand within the first 12-36 hours, leading to neurological deterioration. 1, 3

For Vitamin K Antagonists (Warfarin)

• Administer prothrombin complex concentrates 50 IU/kg plus vitamin K 10 mg immediately 4
• If PCC unavailable, use fresh frozen plasma plus vitamin K 3, 5
• Target PT/aPTT < 1.5 times normal control 1, 4
• Vitamin K maintains the beneficial effect of coagulation correction beyond the short half-life of PCC 3

For Direct Oral Anticoagulants (DOACs)

• Use specific reversal agents if available (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) 1
• If specific reversal unavailable, use PCC 50 IU/kg 1
• Note that patients on DOACs with subdural hematoma show worse outcomes than those on conventional anticoagulants 4

For Antiplatelet Agents

• Do NOT routinely transfuse platelets, as this increases mortality in intracranial hemorrhage 1
• Consider desmopressin 0.4 μg/kg plus tranexamic acid 1-2 g instead 4
• Platelet transfusion only after other reversal measures have failed 1

TEG-Guided Coagulation Management

Use TEG parameters to identify and correct specific coagulation defects beyond initial reversal. 1, 2

High Clotting Rate Time (CRT) on TEG

• Indicates clotting factor deficiency requiring fibrinogen replacement 2
• Administer fibrinogen concentrate (first choice) or cryoprecipitate to achieve fibrinogen level ≥ 1.5-2.0 g/L 1, 2
• If fibrinogen products unavailable, use FFP but recognize it contains only ~70% of normal clotting factor levels 1, 2

Platelet Count Management

• Maintain platelets > 50,000/mm³ for life-threatening hemorrhage 1
• For neurosurgery or ICP monitor placement, target higher platelet counts (>100,000/mm³) 1
• Use 1:1:1 ratio (RBC:Plasma:Platelets) if massive transfusion initiated 1

Ongoing TEG Monitoring

• Continue TEG monitoring to guide additional blood product administration 1, 2
• Target PT/aPTT < 1.5 times normal control throughout perioperative period 1, 4
• TEG provides faster decision-making than conventional coagulation tests for trauma patients 1

Surgical Timing and Approach

Proceed to surgical evacuation once coagulation parameters are corrected, as the extent of underlying brain injury and ability to control ICP are more critical to outcome than absolute timing of surgery. 6

• Perform craniotomy or craniectomy with hematoma evacuation plus ICP monitor placement 5, 4
• Small or asymptomatic hematomas can be managed conservatively while treating coagulopathy 1
• Symptomatic hematomas with mass effect require surgical drainage 1

Postoperative Anticoagulation Management

Hold anticoagulation for 7-10 days after surgery if repeat imaging shows no hematoma expansion. 1, 3

Safety of Temporary Anticoagulation Cessation

• Studies show no ischemic events in patients with mechanical heart valves off anticoagulation for median 7-15 days 1, 3
• One study of 35 patients showed no recurrent ischemic strokes after median 10 days without warfarin 1
• Risk of ischemic event within 30 days is only 2.1% 1

Resumption Protocol

• Restart anticoagulation at previous therapeutic dose after 7-10 days if imaging stable 3
• Consider bridging with low molecular weight heparin until therapeutic INR achieved for high-risk patients (mechanical mitral valve) 3, 7
• Begin prophylactic dose LMWH postoperatively, increasing gradually 5, 7

Critical Pitfalls to Avoid

• Do not delay reversal of anticoagulation - elevated INR enhances hematoma expansion and worsens outcomes 1, 3
• Do not rely solely on conventional coagulation tests (PT/aPTT) - they may not correlate with clinical bleeding or TEG parameters 1, 8
• Do not delay treatment while waiting for laboratory results in severe bleeding 1, 2
• Do not withhold anticoagulation > 2-3 weeks - increases risk of valve thrombosis in mechanical valve patients 3
• Do not routinely transfuse platelets for antiplatelet-associated hemorrhage - increases mortality 1
• Do not use high-dose vitamin K alone without PCC or FFP for rapid reversal 3

Hemodynamic and Physiologic Targets

Maintain these parameters throughout perioperative period: 1

• Mean arterial pressure > 80 mmHg or systolic blood pressure > 100 mmHg 1
• Hemoglobin > 7 g/dL (higher threshold for elderly or limited cardiovascular reserve) 1
• PaO2 60-100 mmHg 1
• PaCO2 35-40 mmHg 1
• Cerebral perfusion pressure ≥ 60 mmHg once ICP monitoring available 1