How should recovery be managed for an elderly patient with a subdural hematoma who is on anticoagulation and has comorbidities such as hypertension or dementia?

Recovery Management for Elderly Patients with Subdural Hematoma on Anticoagulation

For elderly patients with subdural hematoma on anticoagulation, immediately reverse anticoagulation with prothrombin complex concentrate plus vitamin K, surgically evacuate if symptomatic or showing mass effect, and restart anticoagulation approximately 4 weeks post-operatively if no ongoing fall risk exists. 1

Immediate Anticoagulation Reversal

Rapid reversal of anticoagulation is mandatory as soon as subdural hematoma is diagnosed:

• For warfarin-associated subdural hematoma with INR ≥ 2.0, administer 4-factor prothrombin complex concentrate (PCC) over fresh frozen plasma, plus intravenous vitamin K to prevent re-emergence of anticoagulation 2, 1
• For dabigatran, use idarucizumab; for factor Xa inhibitors (apixaban, rivaroxaban), use andexanet alpha or 4F-PCC if andexanet is unavailable 2
• For heparin-related subdural hematoma, administer protamine sulfate 2
• Target prothrombin time/activated partial thromboplastin time < 1.5 times normal control before any neurosurgical intervention 1

Critical pitfall: 30-40% of subdural hematomas expand within the first 12-36 hours, and elevated INR enhances this expansion—delay in reversal worsens neurological outcomes 2

Surgical Decision-Making

Surgical evacuation is indicated for:

• Symptomatic subdural hematoma with significant mass effect, neurological deterioration, or decreased level of consciousness 1
• Hematoma thickness > 5 mm AND midline shift > 5 mm 1
• Glasgow Coma Scale decline of ≥ 2 points 1
• Signs of herniation (anisocoria, bilateral mydriasis) 1

Burr hole drainage is the preferred first-line surgical approach for chronic subdural hematomas, with subdural drain placement to reduce recurrence 1

Conservative management with close neurological monitoring is appropriate for:

• Small or asymptomatic hematomas without significant neurological deficits 1
• Stable patients without mass effect 1
• This requires serial imaging to monitor for progression and regular neurological assessments 1

Managing Comorbidities

Hypertension Management

• In patients with spontaneous intracerebral hemorrhage and hypertension presenting within 6 hours, acutely lower systolic blood pressure to target 140 mmHg (strictly avoiding SBP < 110 mmHg) to reduce hematoma expansion risk 2
• Maintain systolic blood pressure > 100 mmHg or mean arterial pressure > 80 mmHg during emergency interventions 1
• Ensure cerebral perfusion pressure ≥ 60 mmHg when intracranial pressure monitoring is in place 1

Dementia Considerations

Dementia should not be viewed as a general contraindication to anticoagulation or surgical intervention 2

• All patients with dementia should have careful assessment of their ability to understand treatment decisions regarding anticoagulation, with indicative risks of stroke and bleeding provided 2
• Where capacity is lacking, physicians may recommend treatment based on "best medical interest" principle, ideally including next of kin assent 2
• Anticoagulation should only be withheld in selected patients with dementia where compliance and adherence cannot be ensured by a caregiver 2

Falls Risk

Falls and risk of subdural hemorrhage should not automatically contraindicate anticoagulation:

• A Markov decision model demonstrated that a patient would need to fall 295 times for the risk of subdural hematoma to outweigh anticoagulation benefit with warfarin; this number is even higher with NOACs given their lower subdural bleeding risk 2
• Anticoagulation should only be withheld in patients with severe uncontrolled falls (e.g., epilepsy or advanced multisystem atrophy with backwards falls) 2
• The treatment effect of NOACs versus warfarin was consistent in patients at increased versus not increased risk of falling, with larger absolute risk reduction in high-fall-risk patients 2

Anticoagulation Interruption Period

The duration of anticoagulation interruption is typically 7-15 days, with low risk of ischemic events during this period 1

• In a study of 141 patients with intracerebral hemorrhage on warfarin, warfarin was stopped for a median of 10 days with only 2.1% risk of ischemic event within 30 days 2
• The risk of ischemic stroke during cessation was 2.9% in patients with prosthetic heart valve, 2.6% in those with atrial fibrillation and prior embolic stroke 2
• Among 35 patients followed up to 19 days off warfarin after hemorrhage, there were no recurrent ischemic strokes 2

Restarting Anticoagulation

Initiate or resume anticoagulation after 4-8 weeks, choosing an agent with low intracranial bleeding risk 2

• Restart anticoagulation approximately 4 weeks after surgical removal of traumatic subdural hematoma if no ongoing fall risk or alcohol abuse is present 1
• This decision requires evaluation by a multidisciplinary panel (stroke physician/neurologist, cardiologist, neuroradiologist, neurosurgeon) before treatment 2

Factors supporting reinitiation of anticoagulation:

• Bleeding occurred on warfarin or in setting of overdose (versus adequately dosed NOAC) 2
• Younger age 2
• Well-controlled hypertension 2
• Basal ganglia bleed (versus cortical bleed) 2
• No or mild white matter lesions 2
• Surgical removal of subdural hematoma 2
• High risk of ischemic stroke 2

Factors supporting withholding anticoagulation:

• Bleeding occurred on adequately dosed NOAC or during treatment interruption 2
• Older age 2
• Uncontrolled hypertension 2
• Cortical bleed 2
• Severe intracranial bleed 2
• Multiple microbleeds (e.g., >10) 2
• Chronic alcohol abuse 2
• Need for dual antiplatelet therapy after PCI 2

When restarting anticoagulation, NOACs (particularly edoxaban and apixaban) have demonstrated better benefit over warfarin in elderly and frail patients 2

Post-Operative Monitoring

• Close neurological monitoring is essential in the immediate post-operative period 3
• Serial imaging to monitor for recurrence, though recurrence rate does not significantly affect outcome 4
• Antiepileptic drugs are NOT recommended for primary prevention of post-traumatic seizures, as they show no benefit and may worsen neurological outcomes 1
• Consider antiepileptic drugs only if specific risk factors are present, such as chronic subdural hematoma or prior epilepsy 1

Prognostic Factors

Outcome correlates strongly with:

• Glasgow Coma Scale score on admission—patients in good neurologic condition have better chances of recovery 4
• Timing of surgery—functional recovery occurred in 27% when operated within 24 hours versus 54% when operated between 24-72 hours for acute subdural hematomas 5
• Warfarin-related coagulopathy correlates with poor recovery, whereas disturbance in thrombocyte function (usually from aspirin) correlates with improved outcome, though aspirin patients present with better initial GCS scores 4

Critical pitfall: Delaying surgical intervention when neurological deterioration occurs leads to poorer outcomes 1