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Difficulty: MediumNeurosurgery

A 79-year-old man is brought to the emergency department by his daughter due to a 2-day history of worsening confusion and right-sided weakness. He had a mechanical fall approximately one month ago but did not seek medical attention at the time. His past medical history is significant for permanent atrial fibrillation, for which he takes warfarin and metoprolol. On examination, the patient is somnolent but arouses to verbal stimuli. His blood pressure is 155/90 mmHg, and heart rate is 78/min. Neurologic examination reveals a left-sided pupil that is sluggishly reactive to light and right-sided hemiparesis. Laboratory studies show an international normalized ratio (INR) of 2.8. A non-contrast computed tomography (CT) scan of the head demonstrates a large, crescent-shaped, hypodense extra-axial fluid collection over the left cerebral hemisphere with a 13-mm midline shift. Which of the following is the most appropriate next step in management?

  1. A
    Admission to the intensive care unit for conservative observation and withholding of warfarin
  2. B
    Administration of empiric broad-spectrum antibiotics and performance of a lumbar puncture
  3. Administration of prothrombin complex concentrate and urgent burr hole craniostomyAnswer
  4. D
    Immediate transport for magnetic resonance imaging of the brain for detailed parenchymal evaluation
  5. E
    Postponement of invasive interventions until the designated healthcare proxy arrives to provide formal consent

Answer

Administration of prothrombin complex concentrate and urgent burr hole craniostomy
This patient presents with a symptomatic chronic subdural hematoma (cSDH) complicated by significant mass effect, a 13-mm midline shift, and signs of early uncal herniation (somnolence, sluggish left pupil, right hemiparesis). In an anticoagulated patient presenting with a life-threatening intracranial hemorrhage, the most appropriate next step is rapid reversal of the anticoagulation to prevent catastrophic bleeding during intervention. For warfarin, this is achieved with prothrombin complex concentrate (PCC) and intravenous vitamin K. This must be immediately followed by surgical decompression. Burr hole craniostomy is the standard neurosurgical procedure for draining a chronic, liquefied subdural hematoma.

Step-by-Step Solution

1
Identify the primary clinical diagnosis from the history and imaging findings.
The patient has a symptomatic chronic subdural hematoma (cSDH) complicated by mass effect, as evidenced by a 13-mm midline shift.
The crescent-shaped, hypodense extra-axial fluid collection in an elderly patient with a history of falls is classic for a chronic SDH.
2
Assess the acuity and need for surgical intervention.
Urgent surgical decompression is indicated.
The patient is exhibiting signs of early uncal herniation (somnolence, sluggish left pupil, right hemiparesis) alongside significant radiographic midline shift (>10 mm).
3
Determine the necessary preoperative stabilization steps regarding the patient's medications.
Immediate reversal of warfarin anticoagulation is required using prothrombin complex concentrate (PCC) and vitamin K.
Performing neurosurgical interventions on a patient with a therapeutic or elevated INR poses an unacceptable risk of catastrophic intraoperative and postoperative bleeding.

Key Concept

Management of a symptomatic chronic subdural hematoma with impending brain herniation in an anticoagulated patient requires emergent medical reversal of anticoagulation (e.g., PCC for warfarin) followed immediately by surgical decompression via burr hole craniostomy.
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Neurosurgery

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