In a patient over 65 years old with a history of minor head trauma and anticoagulant use, what are the typical presentation, imaging findings, and management options for chronic subdural hematoma?

Chronic Subdural Hematoma in Elderly Patients on Anticoagulants

Typical Presentation

Chronic subdural hematoma (cSDH) in elderly patients typically presents with headache, altered mental status, and hemiparesis, often developing insidiously weeks after seemingly trivial head trauma. 1

The clinical presentation reflects the pathophysiology unique to elderly patients:

• Brain atrophy creates additional intracranial space, allowing subdural hematomas to accumulate slowly and remain asymptomatic initially before causing delayed neurological deterioration. 2
• A membrane forms around the initial clot and becomes the source of recurrent smaller hemorrhages, causing the hematoma to slowly enlarge over time until symptoms emerge. 1
• The most common presenting symptoms are headache, changes in mentation (confusion, memory problems), and hemiparesis (weakness on one side). 1
• Many patients (16% in one series) cannot recall any head trauma, particularly those on anticoagulants—63% of non-trauma cSDH patients were on anticoagulants or antiplatelet agents compared to 42% in the trauma group. 3

Critical Risk Factors to Document

• Anticoagulation status is the single most important risk factor: warfarin carries a 10.2% risk of intracranial hemorrhage after head trauma versus 2.6% for NOACs. 2
• Antiplatelet agents including clopidogrel carry similar bleeding risks and should not be considered safer than anticoagulants—patients on clopidogrel have dramatically higher mortality rates (OR = 14.7). 2, 4
• Age >80 years, history of loss of consciousness or post-traumatic amnesia, and concomitant use of multiple anticoagulant/antiplatelet agents all increase risk of delayed complications. 2

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Imaging Findings

Obtain immediate non-contrast head CT scan regardless of symptom severity or mechanism of injury in all elderly patients (≥65 years) on anticoagulants who sustain any head trauma. 2, 4

CT Imaging Protocol

• All elderly patients on warfarin who sustain a ground-level fall require emergent non-contrast head CT, irrespective of the presence or absence of obvious head injury or symptoms. 4
• Do not withhold CT based on a "minor mechanism"—mechanism severity does not predict intracranial injury in anticoagulated elderly patients. 4
• Among anticoagulated patients with minor head injuries and GCS of 15,29% had intracranial hemorrhage on CT. 4
• Chronic subdural hematomas are accurately diagnosed by either CT or MRI. 1

Follow-Up Imaging Considerations

• If initial CT shows intracranial hemorrhage, obtain repeat head CT within 24 hours because anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% vs 9%). 2, 4
• Neurologically intact patients with a negative initial head CT can be safely discharged without repeat imaging or prolonged observation—the risk of delayed intracranial hemorrhage requiring intervention is extremely low (<1%). 4
• In a prospective cohort of 178 anticoagulated patients with an initial negative CT, only 3 patients (1.7%) developed delayed ICH within 30 days; none required neurosurgery. 4

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Management Options

Immediate Management When Intracranial Hemorrhage Is Detected

If initial CT shows intracranial hemorrhage, immediately discontinue all anticoagulants and antiplatelet agents, obtain urgent neurosurgical consultation, and administer reversal agents. 2, 4

Anticoagulant Reversal Protocol

Anticoagulant	Reversal Strategy	Target
Warfarin	4-factor prothrombin complex concentrate (4F-PCC) plus 5 mg IV vitamin K simultaneously; recheck INR after reversal	INR <1.5 [4]
Apixaban or Rivaroxaban	Andexanet alfa; if unavailable, give 2,000 units of 4F-PCC	Clinical hemostasis [4]
Dabigatran	Idarucizumab 5 g IV; if unavailable, give 50 units/kg activated PCC	Clinical hemostasis [4]

Surgical Management

Surgery is indicated for symptomatic cSDH and is superior to conservative management, promoting equivalent neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. 5

Key surgical considerations:

• Neurosurgical evacuation is generally indicated for hematomas wider than the thickness of the skull. 6
• After successful surgical management, most patients return to their premorbid level of functioning. 1
• Recurrence and reoperation rates in older adults (24% in one series) are similar to younger individuals. 5, 3
• Older adults may be at increased risk for mortality after surgery, though neurologic outcomes remain favorable. 5
• There is no association between recurrence and anticoagulant/antiplatelet agent therapy. 3

Management of Antithrombotic Medications

Anticoagulant medication is associated with increased rebleeding risk (OR 2.7,95% CI 1.42-6.96), but antiplatelet medication is not associated with increased risk of rebleeding. 7

Perioperative Antithrombotic Management Algorithm

• Discontinue all anticoagulants and antiplatelet agents immediately upon diagnosis of cSDH requiring surgery. 2, 4
• In patients at elevated thromboembolic risk, consider early restart of antithrombotic treatment or even operation under continued antithrombotic therapy on an individual basis. 6
• Discontinuation of antithrombotics (including both plasmatic and antiplatelet drugs) is associated with thrombotic complications in 9.1% of patients. 6
• Do not routinely discontinue anticoagulation after negative initial CT in neurologically intact patients, as thromboembolic risk may outweigh the small risk of delayed hemorrhage. 4

Discharge Planning After Negative Initial CT

Neurologically intact patients with a negative initial head CT can be safely discharged with clear written instructions about signs of delayed hemorrhage. 2, 4

Discharge instructions must include:

• Explicit warning signs of delayed hemorrhage: severe headache, vomiting, confusion, weakness, seizure. 4
• Instructions to call emergency services (911) immediately if symptoms arise. 4
• Outpatient referral for fall risk assessment. 4
• Re-evaluation of the anticoagulation risk-benefit ratio. 4

Observation Considerations

Consider brief observation (4-6 hours) before discharge for patients with high-risk features: age >80 years, history of loss of consciousness or amnesia, GCS <15, or concomitant use of multiple anticoagulant/antiplatelet agents. 4

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Common Pitfalls and Caveats

• External scalp bleeding does not predict the presence or absence of intracranial hemorrhage—the two findings are independent. 4
• Avoid routine repeat head CT in stable patients with an initially negative scan, as it adds cost and radiation without improving outcomes. 4
• In patients aged ≥65 years, systolic blood pressure <110 mmHg represents shock and heart rate >90 bpm is abnormal—these are lower thresholds than in younger patients. 4
• Aggressive fluid resuscitation should be avoided because it may exacerbate intracranial bleeding; maintain mean arterial pressure of at least 80 mmHg when traumatic brain injury is suspected. 4