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Difficulty: HardNeurosurgery

An 8181-year-old man arrives at the emergency department accompanied by his son, who reports that his father has become increasingly confused and clumsy over the past month. The patient has a history of a mechanical mitral valve replacement, for which he takes warfarin, as well as hypertension.

On examination, the patient is lethargic but arousable. He exhibits a left-sided facial droop and 4/54/5 strength in his left upper and lower extremities.

Laboratory analysis reveals an International Normalized Ratio (INR) of 3.43.4.

A non-contrast computed tomography (CT) scan of the head reveals a 2.12.1-cm thick crescent-shaped, hypodense extra-axial fluid collection over the right frontoparietal cortex causing a 99-mm leftward midline shift.

What is the most appropriate sequence of interventions for this patient?

  1. Four-factor prothrombin complex concentrate and intravenous vitamin K followed by burr hole craniostomyAnswer
  2. B
    Intravenous fresh frozen plasma followed by decompressive hemicraniectomy
  3. C
    Intravenous dexamethasone therapy followed by admission to the intensive care unit for observation
  4. D
    Intravenous protamine sulfate followed by open craniotomy for hematoma evacuation
  5. E
    Immediate cessation of warfarin followed by serial neuroimaging every 6 hours

Answer

Administration of four-factor prothrombin complex concentrate and intravenous vitamin K, followed by urgent burr hole craniostomy.
The clinical presentation and imaging are consistent with a symptomatic chronic subdural hematoma (cSDH) causing significant mass effect. On a non-contrast head CT, a cSDH appears as a crescent-shaped, hypodense (dark) extra-axial collection. Because the patient is symptomatic (lethargy, hemiparesis) and has a midline shift greater than 55 mm, urgent surgical evacuation via burr hole craniostomy is indicated. Furthermore, because he is therapeutically anticoagulated with warfarin (INR 3.43.4), his coagulopathy must be rapidly reversed prior to surgery to prevent fatal intraoperative bleeding. Four-factor prothrombin complex concentrate (PCC) combined with intravenous vitamin K is the most appropriate reversal strategy, as PCC normalizes the INR much faster than fresh frozen plasma and requires significantly less volume.

Step-by-Step Solution

1
Interpret the clinical and radiographic findings.
Diagnosis of a symptomatic chronic subdural hematoma (hypodense crescentic collection) with brain herniation signs (midline shift, hemiparesis).
Neurological deficits and mass effect dictate the need for mechanical intervention rather than medical management.
2
Identify absolute contraindications to immediate surgery.
The patient is therapeutically anticoagulated with warfarin (INR 3.4).
Operating on a patient with an INR of 3.4 will result in catastrophic intraoperative hemorrhage.
3
Determine the optimal reversal agent and subsequent surgical procedure.
Select 4-factor PCC with Vitamin K for rapid reversal, followed by a burr hole craniostomy.
PCC provides immediate correction of vitamin K-dependent factors without the fluid overload risk of FFP, allowing the standard burr hole decompression to proceed safely.

Key Concept

Symptomatic chronic subdural hematomas with mass effect require surgical evacuation; patients on warfarin require rapid preoperative reversal with four-factor prothrombin complex concentrate (PCC) and vitamin K.
Estimated Time:1m 30s
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Topics

Neurosurgery

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