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Soru

Zorluk: OrtaNeurosurgery

An evaluation is requested for an 81-year-old resident of an assisted living facility who has exhibited a gradual decline in consciousness and right-sided hemiparesis over the last month. The nursing staff notes that the patient became non-verbal this morning. Medical history is significant for paroxysmal atrial fibrillation, for which the patient takes rivaroxaban. Vital signs are within normal limits except for a blood pressure of 162/95 mm Hg. Physical examination confirms dense right-sided weakness and a dilated, unresponsive left pupil. Urgent non-contrast head computed tomography reveals a 2.5-cm crescentic, low-attenuation fluid collection overlying the left cerebral hemisphere, resulting in uncal herniation and 14 mm of subfalcine shift. Which of the following is the most appropriate next intervention for this patient?

  1. Administration of prothrombin complex concentrate and urgent burr hole craniostomyCevap
  2. B
    Cessation of rivaroxaban and admission to the intensive care unit for serial imaging
  3. C
    Endotracheal intubation and hyperventilation to a target PaCO2 of 20 mm Hg
  4. D
    Intravenous administration of high-dose corticosteroids to reduce cerebral edema
  5. E
    Lumbar puncture to assess for occult central nervous system infection

Cevap

Administration of prothrombin complex concentrate and urgent burr hole craniostomy
The patient presents with a symptomatic chronic subdural hematoma causing life-threatening uncal herniation, indicated by a dilated, unresponsive left pupil, right-sided hemiparesis, and a significant midline shift on imaging. The low-attenuation crescentic collection on the CT scan confirms the chronicity of the bleed. Because the patient is actively herniating, emergent surgical decompression (typically via burr hole craniostomy) is required to relieve the mass effect. However, because the patient is taking rivaroxaban (a factor Xa inhibitor), immediate reversal of anticoagulation using prothrombin complex concentrate (or andexanet alfa) must be administered just prior to or concurrently with surgical preparation to prevent uncontrollable intraoperative hemorrhage.

Adım Adım Çözüm

1
Identify the primary diagnosis from the clinical and radiographic findings.
The patient has a chronic subdural hematoma (evidenced by the low-attenuation crescentic collection) complicated by uncal herniation (ipsilateral blown pupil and contralateral hemiparesis).
Accurate diagnosis is required to determine the urgency and necessary type of intervention.
2
Assess the patient's medication history for factors complicating surgical intervention.
The patient is taking rivaroxaban, a direct factor Xa inhibitor, which significantly increases the risk of operative and perioperative bleeding.
Anticoagulation must be reversed prior to any neurosurgical procedure to prevent catastrophic hemorrhage.
3
Determine the definitive next step in management.
Immediate reversal of anticoagulation with a prothrombin complex concentrate (or andexanet alfa) followed by urgent surgical evacuation via burr hole craniostomy.
Surgical decompression is the only definitive treatment to relieve the mass effect and reverse the active brain herniation.

Anahtar Kavram

Patients with a symptomatic chronic subdural hematoma and signs of active herniation require emergent surgical decompression, which must be immediately preceded by the reversal of any concurrent anticoagulation to minimize bleeding risk.
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