warfarin and Hematoma--Subdural

You start another busy shift with a double row of charts waiting to be seen. Your first patient is an elderly man who fell 1 hour prior to presentation. He did not lose consciousness, but he was dazed for a few minutes. He complains of a mild headache but denies any neck pain. He takes warfarin for valvular heart disease. He looks good and has no focal neurological complaints. His mental status is normal, he has a negative head CT scan, and his INR is 3.9. His family wants to take him home, which would help relieve some of the congestion in the ED, but you wonder what would be best. To observe and repeat imaging? Reverse his anticoagulation? Change his dosing regimen of warfarin? In the next room, you quickly evaluate a 51-year-old obese woman with nonspecific back and abdominal pain that started 24 hours before and has slowly progressed to become intolerable. She denies fever, chills, nausea, or vomiting. She is on the last day of a 5-day course of ciprofloxacin for a UTI. She takes warfarin for a pulmonary embolus that occurred 2 months prior. Her hematocrit is mildly decreased, and her white blood count is normal; however, the INR is 6.8. You wonder if her abdominal pain is related to the UTI, or if it could be somehow related to the prolonged INR. In fact, you wonder why her INR is so prolonged...

Topics: Aged; Anticoagulants; Blood Coagulation; Blood Coagulation Factors; Emergency Service, Hospital; Evidence-Based Medicine; Female; Hematoma, Subdural; Hemorrhage; Herb-Drug Interactions; Humans; International Normalized Ratio; Male; Middle Aged; Physical Examination; Plasma; Retroperitoneal Space; Tomography, X-Ray Computed; Warfarin

This chapter addresses the increasing incidence of spinal haematoma after central neuraxis anaesthesia in patients receiving drugs that affect coagulation. Administration of low-molecular-weight heparins in the perioperative period is highlighted because these drugs remain the 'gold standard' for prophylaxis against deep-vein thrombosis. The performance of spinal anaesthesia in patients already receiving antiplatelet drugs is discussed--as well as special warnings in such a setting. In addition, issues such as those concerning the administration of unfractionated heparin, anti-vitamin K drugs or new antiplatelet and antithrombotic medications are addressed. Finally, specific recommendations regarding each class of drug are defined in order to avoid the occurrence of a rare but catastrophic event such as spinal haematoma.

Topics: Anesthesia, Spinal; Anticoagulants; Contraindications; Fibrinolytic Agents; Hematoma, Subdural; Heparin; Heparin, Low-Molecular-Weight; Humans; Platelet Aggregation Inhibitors; Risk Factors; Warfarin

Intraspinal hemorrhage is a rare but dangerous complication of anticoagulant therapy. It must be suspected in any patient taking anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. We describe a patient with hematomyelia, review the literature on hematomyelia and other intraspinal hemorrhage syndromes, and summarize intraspinal hemorrhage associated with oral anticoagulant therapy. The patient (a 62-year-old man) resembled previously described patients with hematomyelia in age and sex. However, he was unusual in having cervical rather than thoracic localization. As with intracranial bleeding, the incidence of intraspinal hemorrhage associated with anticoagulant therapy might be minimized by close monitoring and tight control of the intensity of anticoagulation. However, it is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. If intraspinal hemorrhage is suspected, anticoagulation must be reversed immediately. Emergency laminectomy and decompression of the spinal cord appear mandatory if permanent neurologic sequelae are to be minimized. A high index of suspicion, prompt recognition, and immediate intervention are essential to prevent major morbidity and mortality from intraspinal hemorrhage.

Topics: Administration, Oral; Anticoagulants; Diagnosis, Differential; Hematoma, Epidural, Cranial; Hematoma, Subdural; Hemorrhage; Humans; Laminectomy; Magnetic Resonance Imaging; Male; Middle Aged; Spinal Cord Vascular Diseases; Thromboembolism; Warfarin

In the quest for longevity and as an alternative to Western medicine, there has been a resurgence in traditional remedies. However, several concerns have been raised about the increased use of herbal remedies, including potential interactions with "Western" medicines, the lack of quality control, the assessment of herbal clinical trials, and the adulteration of herbal remedies by traditional prescribers. Taking an herbal history is not usually a part of medical/nursing practice, and patients usually do not readily volunteer such information. In the cerebrovascular and cardiac settings, it is particularly important to gain such a history and to educate patients and family members about the potential interactions of herbal remedies with anticoagulants. Two herbal supplements in particular, ginkgo biloba and garlic, have demonstrated effects on warfarin.

Topics: Acute Disease; Adult; Anticoagulants; Drug and Narcotic Control; Drug Interactions; Female; Food-Drug Interactions; Garlic; Ginkgo biloba; Hematoma, Subdural; Humans; Medical History Taking; Nursing Assessment; Phytotherapy; Plants, Medicinal; Warfarin

Thirteen of 394 (3.3%) regularly dialyzed patients of the Regional Kidney Disease Program developed subdural hematoma. The following factors contributed to formation of subdural hematoma: head trauma, ultrafiltration to control excessive accumulation of fluid and hypertension, anticoagulants, and frequent vascular access infection and clotting. Neurologic symptoms and signs, which may be similar to dialysis disequilibrium, aid only in signifying the presence, not the ultimate localization, of subdural hematoma. Our experience underscores the frequency of bilateral disease, irrespective of neurologic findings. Skull films, lumbar puncture, and electroencephalography were of little diagnostic help. Although valuable and safe, brain scanning was not as useful as desired due to occurrences of false-negative studies and failure to identify bilaterality of lesions. Cerebral angiography was always diagnostic. Surgical intervention yielded disappointing results, and only 2 patients (15%) survived. A review of 9 other patient reports is included.

Topics: Adult; Aged; Central Nervous System Diseases; Cerebral Angiography; Female; Hematoma, Subdural; Humans; Male; Middle Aged; Peritoneal Dialysis; Renal Dialysis; Ultrafiltration; Warfarin; Wounds and Injuries

The primary objective of this study was to evaluate the safety of early warfarin resumption following burr hole drainage for warfarin-associated subdural hemorrhage (SDH). This prospective, single-arm, single-center trial was conducted from February 2008 to April 2010. Inclusion criteria were premorbid warfarin therapy, subacute or chronic SDH requiring burr hole drainage, and an International Normalized Ratio (INR) of >1.5 at presentation. Three days after surgery, warfarin was re-administered to reach the target INR range of 1.7-2.5. Patients were followed by regular INR monitoring and serial brain CT scans, which were performed at 1 week, and at 1, 3, and 6 months after surgery. The primary outcome was recurrent SDH incidence. Twenty patients were enrolled and CT scans performed at 1 week revealed no new intracranial hemorrhage in any patient. Subsequent scans were performed at 1 month on 19 patients, and recurrent SDH was observed in three. However, this recurrence rate (15.8%; 95% CI 0,34) did not exceed that of ordinary SDHs, and all recurrent SDHs were successfully managed by repeated burr hole drainage. The other 16 patients completed their 6-month follow-ups uneventfully. SDH recurrence was found to be associated with older age (≥ 75 years), and a thicker SDH (≥ 25 mm), but not with post-operative anticoagulation status. None of the study subjects experienced a thromboembolic event during the study period. Restarting warfarin therapy does not need to be withheld for more than 3 days after burr hole drainage, particularly in patients with a high thromboembolic risk.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Anticoagulants; Chronic Disease; Decompression, Surgical; Drug Administration Schedule; Female; Hematoma, Subdural; Humans; Male; Middle Aged; Postoperative Hemorrhage; Prospective Studies; Suction; Time Factors; Trephining; Warfarin

Patients with mechanical heart valves are at high thrombotic risk and require warfarin. Among those developing intracranial hemorrhage, limited data are available to guide clinicians with antithrombotic reinitiation. This 13-patient case series of warfarin-associated intracranial hemorrhages found the time to reinitiate antithrombotic therapy (17 days, interquartile range 21.5 days), and changes to international normalized ratio targets were variable and neither correlated with the type, location, or etiology of bleed, nor the valve and associated thromboembolic risk. The initial presentation significantly impacted prognosis, and diligent assessment and follow-up may support positive long-term outcomes.

Topics: Aged; Anticoagulants; Antifibrinolytic Agents; Aortic Valve; Aspirin; Blood Coagulation Factors; Cerebral Hemorrhage; Female; Heart Valve Prosthesis; Hematoma, Subdural; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Mitral Valve; Plasma; Platelet Aggregation Inhibitors; Pregnancy; Retrospective Studies; Subarachnoid Hemorrhage; Subarachnoid Hemorrhage, Traumatic; Thromboembolism; Vitamin K; Warfarin

We present the unusual case of a middle-aged woman who developed a spontaneous subdural haematoma (SSH) while on oral anticoagulation therapy for a total artificial heart (TAH). Headache was followed by paraesthesia and numbness of the left hand. The diagnosis was made from a CT scan. Symptoms resolved with conservative management and careful control of anticoagulation. In this case report, the risk factors and pathophysiology behind this condition are explored. TAHs in their own entity are a rare phenomenon. Coupled with the highly unusual presentation of an SSH in which only a few cases have been documented, we hope to highlight the management of such a difficult case. After navigating this complication, we were able to successfully bridge this patient to a heart transplant 26 days after the SSH.

Topics: Anticoagulants; Female; Heart, Artificial; Hematoma, Subdural; Humans; Middle Aged; Risk Factors; Tomography, X-Ray Computed; Warfarin

We report a case of spontaneous intracranial hypotension successfully treated with repetitive epidural blood patch after warfarin reversal. A 75-year-old man presented with a 2-week history of headache. He was being treated with warfarin for atrial fibrillation. Neurological examination on admission showed mild disorientation. Prothrombin time-international normalized ratio(PT-INR)was elevated to 2.43. Initial magnetic resonance images of the brain demonstrated bilateral subdural hematomas, distortion of midbrain and diffuse pachymeningeal enhancement. Conservative treatments with bed rest and hydration were administered. On the third posthospital day, he became lethargic and emergently underwent epidural blood patch(EBP)at lumbar level. Consciousness disturbance improved immediately but reappeared 12 hours after the EBP. The second EBP was performed but consciousness level decreased again 12 hours later. The effect of warfarin was reversed by administration of vitamin K and fresh frozen plasma before the third EBP. After the procedure, he became alert. The findings of neurological examination did not change but a CT on day 12 revealed increase in volume of left-sided subdural hematoma. He underwent EBP and evacuation of hematoma. The neurological findings remained unchanged. A CT on the 17th posthospital day showed increase of right-sided subdural hematoma, and EBP and evacuation of hematoma were then performed. After the 5th EBP, the clinical course was uneventful. Predictors for successful EBP are not fully clarified. In patients who undergo anticoagulation therapy, EBP may be ineffective and normalization of coagulability required.

Topics: Aged; Anticoagulants; Blood Patch, Epidural; Brain; Hematoma, Subdural; Humans; Intracranial Hypotension; Magnetic Resonance Imaging; Male; Warfarin

Topics: Adult; Afibrinogenemia; Fibrinolytic Agents; Hematoma, Subdural; Humans; Liver Transplantation; Male; Warfarin

Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening.. Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)-documented isolated SDH presenting to a university-affiliated, urban, 100,000-annual-visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model.. A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors-SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127.. Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Clopidogrel; Cohort Studies; Decision Support Techniques; Emergency Service, Hospital; Female; Glasgow Coma Scale; Hematoma, Subdural; Humans; Likelihood Functions; Male; Middle Aged; Neuroimaging; Neurosurgical Procedures; Platelet Aggregation Inhibitors; Retrospective Studies; Risk Assessment; Sensitivity and Specificity; Ticlopidine; Warfarin; Young Adult

Compared to conventional therapy, several studies with prothrombin complex concentrate (PCC) have recently demonstrated its superior efficacy in rapidly replacing vitamin K-dependent factors for patients with life-threatening hemorrhage. We present a novel use of PCC in a patient with intracranial hypotension, who had received warfarin for treatment of cortical vein thrombosis. However, after anticoagulation, she proceeded to develop bilateral subdural hematomas with descent of cerebellar tonsils. Given the possibility of an occult dural puncture during labor analgesia, an epidural blood patch was performed after administration of PCC and normalization of coagulation parameters, with prompt improvement of the patient's headache.

Topics: Blood Coagulation Factors; Blood Patch, Epidural; Female; Hematoma, Subdural; Hemostatics; Humans; Intracranial Thrombosis; Treatment Outcome; Warfarin; Young Adult

Oral anticoagulation is a common prophylactic therapy for several diseases with a high thromboembolic risk. Such medication harbors a possible hemorrhage risk, with a special risk for subdural hematoma (SDH). The safety and efficacy of resumption of oral anticoagulation versus long-term discontinuation has not been fully clarified in patients who experienced SDH while under treatment with oral anticoagulation.. We investigated the outcome of 49 patients who were identified retrospectively to have a SDH while receiving oral anticoagulation.. Most bleeding occurred while patients were within the recommended therapeutic window for oral anticoagulation. Mortality was 15%. The event-free survival probability was higher in the group of patients with reinstitution of phenprocoumon therapy than in the group without. Over a median follow-up of 32 months, thromboembolic events occurred in 4 of 23 patients without oral anticoagulation versus in none of 15 patients with phenprocoumon; hemorrhagic complications occurred in 1 in 23 versus 3 in 15 patients.. Reinstitution of oral anticoagulation with phenprocoumon after previous SDH appears to have an acceptable risk for hemorrhagic complications. Decision making might consider case-by-case differences. To establish specific guidelines, prospective large cohort studies are needed.

Topics: Aged; Aged, 80 and over; Anticoagulants; Disease-Free Survival; Female; Follow-Up Studies; Hematoma, Subdural; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Phenprocoumon; Retrospective Studies; Thromboembolism; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Cerebral Hemorrhage; Female; Hematoma, Subdural; Humans; Medication Errors; Risk Assessment; Tomography, X-Ray Computed; Warfarin

Despite recent progress, prognosis for the elderly (defined as aged ≥70 years) afflicted by traumatic brain injury (TBI) is unfavorable and surgical intervention remains controversial. Research during the past decade on the mortality rates or prognostic factors for survival in the elderly is limited.. We analyzed 97 patients aged ≥70 years who were treated surgically for closed TBI at our neurosurgical unit between January 1, 2003 and December 31, 2012. In addition, we analyzed 22 patients aged ≥70 years who had sustained a closed TBI and on whom no neurosurgical intervention was performed. Outcome in both groups was measured as 30-, 90- and 180-day mortality.. Surgically treated patients: median age, 76 years' 30-day overall mortality rate, 36%. Higher mortality was seen with lower level of consciousness, high energy trauma, one pupil fixed and dilated, and more extensive intracranial pathology. Presence of warfarin, more advanced age, or degree of midline shift were not associated with worsened outcome. Patients not treated neurosurgically: median age. 81.5 years; 30-day overall mortality rate, 23%. Mortality for patients with Glasgow coma scale (GCS) 10-15 was 6%, GCS 6-9 67%, and GCS 3-5 100%.. Selected patients aged ≥70 years can benefit from surgical intervention for closed TBI. Level of consciousness, radiologic type of injury, mechanism of injury, and pupil abnormalities should be carefully evaluated. There also seems to exist a group of patients in whom surgical intervention offers little benefit, as mortality rate is low without surgical intervention.

Topics: Acute Disease; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Brain Injuries; Craniotomy; Female; Glasgow Coma Scale; Head Injuries, Closed; Hematoma, Subdural; Humans; Male; Prognosis; Retrospective Studies; Risk Factors; Sweden; Treatment Outcome; Warfarin

A primary goal in the treatment of patients with warfarin-associated subdural hematoma (SDH) is reversal of coagulopathy with fresh-frozen plasma. Achieving the traditional target international normalized ratio (INR) of 1.3 is often difficult and may expose patients to risks of volume overload and of thromboembolic complications. This retrospective study evaluates the risk of mild elevations of INR from 1.31 to 1.69 at 24 hours after admission in patients presenting with warfarin-associated SDH.. Sixty-nine patients with warfarin-associated SDH and 197 patients with non-warfarin-associated SDH treated at a single institution between January 2005 and January 2012 were retrospectively identified. Charts were reviewed for patient age, history of trauma, associated injuries, neurological status at presentation, size and chronicity of SDH, associated midline shift, INR at admission and at hospital Day 1 (HD1), concomitant aspirin or Plavix use, platelet count, and medical comorbidities. Patients were stratified according to use of warfarin and by INR at HD1 (INR 0.8-1.3, 1.31-1.69, 1.7-1.99, and ≥ 2). The groups were evaluated for differences the in rate of radiographic expansion of SDH and in the rate of clinically significant SDH expansion resulting in death, unplanned procedure, and/or readmission.. There was no difference in the rate of radiographic versus clinically significant expansion of SDH between patients not on warfarin and those on warfarin (no warfarin: 22.3% vs 20.3%, p = 0.866; warfarin: 10.7% vs 11.6%, p = 0.825), but the rate of medical complications was significantly higher in the warfarin subgroup (13.3% for patients who did not receive warfarin vs 26.1% for those who did; p = 0.023). For warfarin-associated SDH, there was no difference in the rate of radiographic versus clinically significant expansion between patients reversed to HD1 INRs of 0.8-1.3 and 1.31-1.69 (HD1 INR 0.8-1.3: 22.5% vs 20%, p = 1; HD1 INR 1.31-1.69: 15% vs 10%, p = 0.71).. Mild INR elevations of 1.31-1.69 in warfarin-associated SDH are not associated with a markedly increased risk of radiographic or clinically significant expansion of SDH. Larger prospective studies are needed to determine if subtherapeutic INR elevations at HD1 are associated with smaller increases in risk of SDH expansion.

Topics: Aged; Anticoagulants; Disease Progression; Female; Hematoma, Subdural; Hospitalization; Humans; International Normalized Ratio; Male; Middle Aged; Plasma; Retrospective Studies; Risk Factors; Survival Rate; Treatment Outcome; Warfarin

Thromboembolic events and anticoagulation-associated bleeding events represent frequent complications following cardiac mechanical valve replacement. Management guidelines regarding the timing for resuming anticoagulation therapy following a surgically treated subdural hematoma (SDH) in patients with mechanical valves remains to be determined.. To determine optimal anticoagulation management in patients with mechanical heart valves following treatment of SDH.. Outcomes were retrospectively reviewed for 12 patients on anticoagulation therapy for thromboembolic prophylaxis for mechanical cardiac valves who underwent surgical intervention for a SDH at the Johns Hopkins Hospital between 1995 and 2010.. The mean age at admission was 71 years. All patients had St. Jude's mechanical heart valves and were receiving anticoagulation therapy. All patients had their anticoagulation reversed with vitamin K and fresh frozen plasma and underwent surgical evacuation. Anticoagulation was withheld for a mean of 14 days upon admission and a mean of 9 days postoperatively. The average length of stay was 19 days. No deaths or thromboembolic events occurred during the hospitalization. Average follow-up time was 50 months, during which two patients had a recurrent SDH. No other associated morbidities occurred during follow-up.. Interruptions in anticoagulation therapy for up to 3 weeks pose minimal thromboembolic risk in patients with mechanical heart valves. Close follow-up after discharge is highly recommended, as recurrent hemorrhages can occur several weeks after the resumption of anticoagulation.

Topics: Aged; Anticoagulants; Aspirin; Enoxaparin; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hematoma, Subdural; Humans; Male; Middle Aged; Morbidity; Patient Discharge; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Thromboembolism; Warfarin

Topics: Alabama; Anticoagulants; Drug Monitoring; Hematoma, Subdural; Humans; Liability, Legal; Malpractice; Nurse Practitioners; Warfarin

Acute subdural hematomas (SDHs) impart serious morbidity and mortality on the elderly population, with only 5% of those older than 65 years of age attaining functional independence. Despite its widespread use, oral antithrombotic therapy (OAT) in the context of acute SDH has not been extensively studied. The authors sought to evaluate the impact of premorbid OAT on recurrence of SDH, radiographic outcome, and mortality in patients undergoing surgical evacuation of an acute SDH.. The authors conducted a retrospective comparative cohort study reviewing all surgically treated cases of acute SDH at their institution between September 2005 and December 2008. They assessed baseline demographics, coagulation parameters, surgical management, and clinical course. Study end points included additional craniotomy for SDH reaccumulation, follow-up Rotterdam score, recurrent SDH volumetric analysis, Glasgow Outcome Score, and death.. A total of 300 patients with acute SDH treated by craniotomy were assessed. Of these patients, 49% (148 patients) were receiving OAT. Of those who were on a regimen of OAT, 49% were taking warfarin (mean international normalized ratio 3.1 ± 1.8), 31% were receiving antiplatelet therapy, and 20% were on a regimen of a combination of agents. On presentation, 72% of those using OAT received reversal agents. Recurrence of SDH necessitating additional evacuation was not significantly different with respect to premorbid OAT status (13% vs 14%). Patients with a history of OAT did not demonstrate a significant difference in Rotterdam score (2 vs 2), recurrent SDH volume (24.1 vs 19.6 cm(3)), GOS score (4 vs 3), or mortality (21% vs 24%). These findings remained stable after controlling for age, injury mechanism, and injury severity.. Premorbid OAT was not a significant risk factor for recurrence of SDH necessitating additional evacuation following acute SDH. Additionally, postoperative Rotterdam score, volume of SDH reaccumulation, and overall mortality were not predicted by antithrombotic history. While premorbid use may predispose the patient to an SDH, OAT does not increase the risk of morbidity or mortality following surgical intervention.

Topics: Acute Disease; Administration, Oral; Adult; Aged; Aged, 80 and over; Cohort Studies; Decompressive Craniectomy; Female; Fibrinolytic Agents; Glasgow Outcome Scale; Hematoma, Subdural; Humans; Male; Middle Aged; Reoperation; Retrospective Studies; Risk Factors; Secondary Prevention; Survival Rate; Treatment Outcome; Warfarin

We present a retrospective, case-controlled study of the degree of over-warfarinisation and the frequency of International Normalized Ratio (INR) monitoring in patients with spontaneous intracranial haemorrhage (ICH) compared with a control group without ICH. A higher proportion of patients with ICH were taking warfarin than patients in the control group (33/221 [15%] versus 16/201 [8%], p<0.05). There was no significant difference between the ICH group and the controls in the mean INR of warfarinised patients on presentation, the mean INR when last measured prior to presentation, or in the number of days since the INR was last tested. There was no correlation between the time since the INR was last measured and the INR on presentation. Only 2 (6%) of patients were excessively anticoagulated at the time of ICH. Thus, in this study, warfarin use was associated with an increased risk of ICH despite appropriate community INR monitoring and therapeutic anticoagulation.

Topics: Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Cerebral Hemorrhage; Chi-Square Distribution; Drug Monitoring; Female; Hematoma, Subdural; Humans; International Normalized Ratio; Male; Middle Aged; Retrospective Studies; Time Factors; Warfarin

Topics: Accidents, Traffic; Aged; Air Bags; Anticoagulants; Atrial Fibrillation; Female; Head Injuries, Closed; Hematoma, Subdural; Humans; International Normalized Ratio; Warfarin

Antenatal intracranial hemorrhage is a rare cause of intrauterine fetal death, with an incidence of 4.6-5.1% in autopsy studies of stillborn fetuses. Warfarin-associated fetal bleeding is also a rare problem, with an incidence of 4.3% in the literature. We present a case of warfarin-induced subdural hematoma occurring in the second trimester.

Topics: Abortion, Eugenic; Adult; Anticoagulants; Female; Fetal Diseases; Hematoma, Subdural; Humans; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy Trimester, Second; Ultrasonography, Doppler, Color; Ultrasonography, Prenatal; Warfarin

The elderly population is at an increased risk for major bleeding, possibly due to increased sensitivity to anticoagulation, multiple comorbidities, and polypharmacy. Elderly patients receiving antiplatelet and anticoagulant therapy have an additional risk for bleeding. Omega-3 fatty acids, also known as fish oil, have been used for hyperlipidemia, coronary heart disease, hypertension, and other conditions. Some studies have demonstrated that consumption of fish oil concentrate, n-3 polyunsaturated fatty acid (n-3 PUFA), results in cardiovascular benefits that include reductions in mortality, sudden death, nonfatal myocardial infarction, and thrombotic stoke, as well as improvement in graft patency. The mechanism of action of n-3 PUFA is not completely understood, but a dual antiplatelet and anticoagulant effect has been proposed. Few data exist on whether or not fish oil can be used safely with other antiplatelet or anticoagulant drugs. We report the case of a patient who after a minor fall developed a subdural hematoma requiring craniotomy that likely was precipitated by concomitant use of high-dose omega-3 fatty acids 6 g/day with both aspirin and warfarin. These findings are important because of the wide availability of omega-3 fatty acids and the propensity for use of complementary and alternative medicine in patients with cardiovascular disease who are already taking antiplatelet and/or anticoagulant agents. Judicious use of these combinations is advised, and pharmacists can play an important role in educating patients and other health care providers about the bleeding risks associated with combination therapy.

Topics: Accidental Falls; Aged; Anticoagulants; Aspirin; Drug Interactions; Fatty Acids, Omega-3; Hematoma, Subdural; Humans; Male; Platelet Aggregation Inhibitors; Warfarin

The ABC/2 formula is a reliable estimation technique of intracerebral hematoma volume. However, oral anticoagulant therapy (OAT)-related intracerebral hemorrhage (ICH) compared with primary ICH is based on a different pathophysiological mechanism, and various shapes of hematomas are more likely to occur. Our objective was to validate the ABC/2 technique based on analyses of the hematoma shapes in OAT-related ICH.. We reviewed the computed tomography scans of 83 patients with OAT-associated intraparenchymal ICH. Location was divided into deep, lobar, cerebellar, and brain stem hemorrhage. Shape of the ICH was divided into (A) round-to-ellipsoid, (B) irregular with frayed margins, and (C) multinodular to separated. The ABC/2 technique was compared with computer-assisted planimetric analyses with regard to hematoma site and shape.. The mean hematoma volume was 40.83+/-3.9 cm3 (ABC/2) versus 36.6+/-3.5 cm3 (planimetric analysis). Bland-Altman plots suggested equivalence of both estimation techniques, especially for smaller ICH volumes. The most frequent location was a deep hemorrhage (54%), followed by lobar (21%), cerebellar (14%) and brain stem hemorrhage (11%). The most common shape was round-to-ellipsoid (44%), followed by irregular ICH (31%) and separated and multinodular shapes (25%). In the latter, ABC/2 formula significantly overestimated volume by +32.1% (round shapes by +6.7%; irregular shapes by +14.9%; P ANOVA <0.01). Variation of the denominator toward ABC/3 in cases of irregularly and separately shaped hematomas revealed more a precise volume estimation with a deviation of -10.3% in irregular and +5.6% in separately shaped hematomas.. In patients with OAT-related ICH, >50% of bleedings are irregularly shaped. In these cases, hematoma volume is significantly overestimated by the ABC/2 formula. Modification of the denominator to 3 (ie, ABC/3) measured ICH volume more accurately in these patients potentially facilitating treatment decisions.

Topics: Algorithms; Brain; Cerebral Hemorrhage; Hematoma, Subdural; Humans; Image Processing, Computer-Assisted; Models, Statistical; Prognosis; Prospective Studies; Software; Stroke; Thrombolytic Therapy; Tomography, X-Ray Computed; Warfarin

In this report the authors describe the use of the hemostatic agent recombinant activated factor VII (rFVIIa) in the perioperative treatment of hemorrhages in the central nervous system that are associated with warfarin therapy.. Two patients sustained hemorrhages within the spinal canal, and the other two had acute intracranial subdural hematomas. All patients had normal platelet counts, activated partial thromboplastin times, and fibrinogen levels, and all received fresh frozen plasma in conjunction with rFVIIa. The initial international normalized ratios (INRs) ranged from 1.9 to 5.6. Each dose of rFVIIa was 1200 microg, ranging from 16 to 22 microg/kg of body weight. Two patients received two perioperative doses of rFVIIa; the others required just one dose before surgery. The INR normalized within 2 hours of administration of rFVIIa in all patients. There were no thromboembolic complications, and surgical blood loss was less than 100 ml for all operations.. This clinical experience indicates that rFVIIa may be safe and effective as the initial hemostatic agent for rapid reversal of orally administered anticoagulation medications in patients who require urgent neurosurgical intervention.

Topics: Acute Disease; Aged; Anticoagulants; Craniotomy; Factor VII; Factor VIIa; Female; Heart Valve Prosthesis; Hematoma, Subdural; Hematoma, Subdural, Acute; Hemostasis, Surgical; Humans; Male; Middle Aged; Preoperative Care; Recombinant Proteins; Treatment Outcome; Warfarin

Antivitamin K treatments (AVK) are related to increased morbidity and mortality, notably in elderly patients. The International Normalized Ratio (INR) should be well controlled and its stabilisation within the therapeutic range help to prevent the haemorrhagic complications.. A one-year prospective survey on all the cases of excess AVK was conducted in hospitalised patients aged over 70.. During the study period, 225 hospitalised patients treated with AVK (mean age 84 years) were identified: 62% received warfarin, 19% fluindione, 8% acenocoumarol and 11% received several successive AVK. During this period, 1.904 INR measurements were recorded: 97 (5.1%) were > or =5.0 and 12 (0.63%) were > or =9.0. In all, 59 patients (23.1%) exhibited one or several episodes of excess AVK (INR > or =5.0) and 57 exhibited a target INR of 2.5. Three patients died of accidental haemorrhage--two of them due to intra-cerebral bleeding--among the 59 patients with excess AVK. In three cases, the INR was greater than 7.0 at the time of the accident.. In half of the cases of excess, the episode occurred during the month following initiation of treatment with AVK. In nearly two thirds of cases, a change had been made in drug therapy in the 10 days preceding the excess, with the prescription of a drug enhancing the effect of the AVK: anti-infection agents (antibiotics and anti-fungals) and amiodarone were the drugs most frequently involved. Oral or intravenous vitamin K1 was administered in only 19% of cases.. In very old patients treated with oral anticoagulants, certain risk factors must be identified: the initiation period of treatment, the occurrence of an intercurrent disease and the subsequent change in the drug therapy. INR monitoring should be intensified in order to detect any excess and, if detected, ensure the optimal management of the patient.

Topics: 4-Hydroxycoumarins; Aged; Aged, 80 and over; Amiodarone; Anti-Arrhythmia Agents; Anti-Bacterial Agents; Anticoagulants; Antifungal Agents; Coma; Drug Administration Schedule; Drug Overdose; Drug Synergism; Female; Hematoma, Subdural; Hemorrhage; Hospitalization; Humans; Indenes; International Normalized Ratio; Male; Prospective Studies; Pulmonary Embolism; Thrombocytopenia; Vitamin K; Warfarin

A 65 year old man, anticoagulated for cardiac problems, developed hemiparesis while training for race walking. A computed tomography scan showed a chronic subdural haematoma. This is the first report of a chronic subdural haematoma possibly caused by the jarring action of race walking.

Topics: Aged; Anticoagulants; Chronic Disease; Hematoma, Subdural; Humans; Male; Radiography; Walking; Warfarin

To study the demographic and clinical characteristics of patients with antiphospholipid syndrome (APS) with serious haemorrhagic complications of anticoagulant treatment in an attempt to establish risk factors for bleeding.. Patients with APS who were attending our lupus unit and who presented with severe bleeding while receiving oral anticoagulation were studied retrospectively. Severe bleeding was defined by the need for admission to hospital. Demographic data, clinical features, concomitant diseases and drugs, warfarin doses, duration of anticoagulation, and International Normalised Ratios (INR) at the time of bleeding were collected.. Fifteen patients were included in the study (12 with systemic lupus erythematosus (SLE) plus APS and 3 with primary APS). The median age was 41.7 (range 27-66) and the median duration of the disease was 12.9 years (range 3-22). Duration of anticoagulation was between 10 days and 17 years. The INR at the time of bleeding was under 3 in 4 patients, between 3 and 4 in 5 patients and above 4 in 6 patients. There were 4 episodes of subdural haematoma, 4 episodes of renal haematoma (two after renal biopsy), 2 episodes of ovarian haemorrhage, 2 episodes of rectal haemorrhage, 1 episode of menorrhagia, 1 episode of haemarthrosis, and 1 episode of spinal haematoma. Concomitant drugs were aspirin in 9 patients, antibiotics in 2 patients, and azathioprine in 3 patients. In 6 patients hypertension was present as a concomitant disease. There were no deaths due to bleeding. Anticoagulant treatment was restarted in all patients and 3 of them had a new episode of bleeding.. No relation was established between age, duration of oral anticoagulant treatment, and bleeding. Concomitant drugs, mainly aspirin, and high blood pressure were present at the time of bleeding in a large number of patients.

Topics: Adult; Aged; Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Antiphospholipid Syndrome; Aspirin; Female; Hemarthrosis; Hematoma; Hematoma, Subdural; Hemorrhage; Humans; Hypertension; Kidney Diseases; Male; Menorrhagia; Middle Aged; Ovarian Diseases; Recurrence; Risk Factors; Thrombosis; Warfarin

There is a perception that patients who develop a chronic subdural haematoma (CSDH), whilst taking warfarin, do less well than those not taking warfarin. This study looks at such patients to determine the truth of this perception. A retrospective analysis of two time periods (1990-1992 and 1995-1997) looking at all patients with CSDH admitted to this neurosurgical unit for treatment, to determine the incidence and to look more closely at those on warfarin. The influence of warfarin on the incidence, severity and outcome has been studied. Between 1990 and 1992, 11.8% of those patients with CSDH were taking warfarin, whilst in 1995-1997 20% were on warfarin. The overall number of referrals of CSDH increased from 34 to 150 patients during these time periods. There were no differences in age, sex or other medical disorders between the two groups. No adverse events occurred when the warfarin was stopped temporarily for treatment of the CSDH. There was no increase in recurrence rate in those on warfarin, compared with those not on warfarin. This study, whilst demonstrating an increase in the number of referrals of CSDH and patients with CSDH taking warfarin, has not demonstrated an adverse effect of the warfarin on the outcome of treatment for CSDH. The authors suggest recommencing warfarin 3 weeks after surgical evacuation of CSDH in anticoagulated patients.

Topics: Aged; Aged, 80 and over; Anticoagulants; Chronic Disease; Female; Glasgow Coma Scale; Glasgow Outcome Scale; Hematoma, Subdural; Humans; Male; Middle Aged; Recurrence; Retrospective Studies; Treatment Outcome; Warfarin

A retrospective analysis was performed of all patients who received operative intervention for subdural haematoma at the Beaumont neurosurgical unit between 1994 and 1997 inclusive. There were 123 spontaneous (mean age 74 +/- 5 years) and 77 traumatic haematomas (mean age 43 +/- 23 years) in the series. Ninety three patients (76%) in the spontaneous group were on antiplatelet agents or anticoagulants (78 aspirin, 15 warfarin) and the indication for their use was unknown in twenty four patients (19%). The re-operation rate in the group on aspirin and anticoagulants was twice that in the non aspirin / non anticoagulant group. These results highlight a significant medical problem and emphasise the need for cautious use of antiplatelet and anticoagulant agents, particularly in the elderly.

Topics: Adult; Aged; Anticoagulants; Aspirin; Female; Hematoma, Subdural; Humans; Male; Prevalence; Reoperation; Retrospective Studies; Warfarin

The incidence of spontaneous intracranial haemorrhage has increased markedly in line with the increased use of oral anticoagulant agents. Recent guidelines for reversal of this acquired coagulation defect in an emergency have been established, but they are not adhered to in all centres. Our unit is referred between 20 and 60 patients per year (1994-1999) who are anticoagulated and require urgent neurosurgical intervention. In order to investigate this, we performed a prospective study using prothrombin complex concentrate (PCC). PCC was given to the first six patients with intracranial haemorrhage admitted to the neurosurgical unit requiring urgent correction of anticoagulation (Group 1) and compared with patients receiving standard treatment with fresh frozen plasma and vitamin K (Group 2). Mean International Normalised Ratios of Group 1 were 4.86 pretreatment and 1.32 posttreatment, and of Group 2 were 5.32 and 2.30, respectively. Results for complete reversal and reversal time were significant for PCC with p < 0.001. We recommend PCC for rapid and effective reversal of warfarin in life-threatening neurosurgical emergencies.

Topics: Adult; Aged; Anticoagulants; Blood Coagulation Factors; Cerebral Hemorrhage; Emergencies; Female; Hematoma, Subdural; Humans; International Normalized Ratio; Male; Middle Aged; Pilot Projects; Preoperative Care; Prospective Studies; Subarachnoid Hemorrhage; Vitamin K; Warfarin

Topics: Accidental Falls; Aged; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Decision Support Techniques; Fibrinolytic Agents; Hematoma, Subdural; Humans; Life Expectancy; Markov Chains; Risk Factors; Treatment Outcome; Warfarin

Topics: Anticoagulants; Back Pain; Cranial Nerve Diseases; Female; Heart Valve Prosthesis; Hematoma, Subdural; Heparin; Humans; Magnetic Resonance Imaging; Middle Aged; Risk; Spinal Cord Compression; Spinal Puncture; Thromboembolism; Urinary Catheterization; Urinary Retention; Warfarin

Topics: Aged; Anticoagulants; Fatal Outcome; Hematoma, Subdural; Humans; Male; Movement; Warfarin

Four patients with prosthetic heart valves suffered intracranial hemorrhage (cerebral hemorrhage in one patient, cerebellar hemorrhage in one, and chronic subdural hematoma in two) during long-term oral anticoagulant drug therapy (warfarin). In all patients, warfarin was discontinued and its effect neutralized by vitamin K, then surgery was performed after the thrombotest value exceeded 50%. No uncontrollable bleeding occurred at surgery. Warfarin was discontinued until 3-7 days postoperatively. Intravenous heparin administration was used to prevent embolic complications and the dose was modified based on the activated clotting time measured at the bedside. One patient, who could not receive heparin administration because of massive bleeding, developed myocardial infarction due to coronary artery thromboembolism 2 days after operation and died 4 days later. The other patients received heparin administration and were alive and well at the most recent follow-up examinations. Heparin administration monitored by activated clotting time is a useful method to prevent embolic and bleeding complications in the surgical treatment of intracranial hemorrhage in patients with prosthetic heart valves receiving long-term anticoagulant therapy.

Topics: Cerebral Hemorrhage; Child; Chronic Disease; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Middle Aged; Time Factors; Warfarin

To explore the rational use of anticoagulants, especially among the elderly, balancing antithrombotic efficacy and risk for hemorrhage. Previous prospective studies have not provided powerful assessments of risk factors for intracranial hemorrhage, the dominant complication in reversing the anticoagulant decision.. Case-control analysis.. A large general hospital and its anticoagulant therapy unit.. 121 consecutive adult patients taking warfarin who were hospitalized with intracranial hemorrhage were each matched to three contemporaneous controls randomly selected from among outpatients managed by our hospital anticoagulant therapy unit.. 77 patients had intracerebral hemorrhage (46% fatal) and 44 had subdural hemorrhage (20% fatal). The prothrombin time ratio (PTR) was the dominant risk factor for intracranial hemorrhage. For each 0.5 increase in PTR over the entire range, the risk for intracerebral hemorrhage doubled (odds ratio, 2.1; 95% CI, 1.4 to 2.9). For subdural hemorrhage, the risk was unchanged over the PTR range from 1.0 to 2.0 but rose dramatically above a PTR of 2.0 (approximate international normalized ratio, 4.0). Age was the only other significant independent risk factor for subdural hemorrhage (odds ratio, 2.0 per decade; CI, 1.3 to 3.1). For intracerebral hemorrhage, age was of borderline significance (odds ratio, 1.3 per decade; CI, 1.0 to 1.6) after controlling for PTR and the two other independent risk factors: history of cerebrovascular disease (odds ratio, 3.1; CI, 1.7 to 5.6) and presence of a prosthetic heart valve (odds ratio, 2.8; CI, 1.3 to 5.8).. The results emphasize the importance of maintaining the prothrombin time ratios under 2.0 and the need for especially careful use of warfarin in the elderly.

Topics: Aged; Aged, 80 and over; Ambulatory Care; Case-Control Studies; Cerebral Hemorrhage; Female; Hematoma, Subdural; Humans; Male; Middle Aged; Prothrombin Time; Risk Factors; Statistics as Topic; Warfarin

Topics: Aged; Aspirin; Cerebral Infarction; Dysarthria; Female; Hand; Hematoma, Subdural; Humans; Paresthesia; Thrombocytopenia; Tomography, X-Ray Computed; Warfarin

Spinal subdural hematoma (SSH) is an uncommon entity. There is a higher incidence among patients with a bleeding diathesis and among those with a bleeding diathesis having a lumbar puncture. The case reported here is of a 65-year-old woman on oral anticoagulants presenting with atypical symptoms who developed SSH over a six-hour period. Emergency investigation and treatment are required because recovery is inversely related to the length of time of spinal cord compression. A review of the literature revealed 37 previously reported cases of nonmajor traumatic SSH.

Topics: Back Pain; Female; Hematoma, Subdural; Humans; Middle Aged; Spinal Cord Compression; Time Factors; Warfarin

Although spinal subdural hematoma is a rare condition, it has a higher incidence in persons with a bleeding diathesis and in those with a bleeding diathesis who have had a lumbar puncture. We report a case of a 65-year-old woman on oral anticoagulants presenting with atypical symptoms who developed a spinal subdural hematoma over a six-hour period. This resulted in complete paraplegia of her lower extremities with no improvement after surgical spinal cord decompression.

Topics: Female; Hematoma, Subdural; Hemorrhagic Disorders; Humans; Laminectomy; Middle Aged; Paraplegia; Spinal Cord Compression; Spinal Diseases; Warfarin

Topics: Chronic Disease; Drainage; Follow-Up Studies; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Warfarin

Topics: Adult; Aortic Valve Insufficiency; Aortic Valve Stenosis; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Mitral Valve Stenosis; Postoperative Complications; Warfarin

Topics: Administration, Oral; Aged; Anticoagulants; Female; Hematoma, Subdural; Herpes Zoster; Humans; Hyperesthesia; Neuralgia; Paraplegia; Prothrombin Time; Warfarin

A case of spinal subdural hematoma occurring in association with anticoagulant therapy is reported. Seven similar cases from the literature are reviewed the emphasis on the clinical features, investigation, and the results of treatment. The prognosis for recovery is good, only if the condition is diagnosed and the clot evacuated before severe spinal cord compression and subsequent ischemic necrosis has occurred.

Topics: Aged; Anticoagulants; Female; Hematoma, Subdural; Humans; Spinal Cord Compression; Warfarin

A case of spontaneous subdural hematoma in the cervicothoracic region associated with a small meningioma in a patient on anticoagulant therapy is presented. The neurological complications of anticoagulant therapy are discussed briefly. Progressive neurological deterioration in a patient on anticoagulant therapy should prompt the performance of an emergency myelogram and a possible laminectomy in spite of the potential risks of these procedures. Intraspinal bleeding occurs more frequently in the form of an epidural hematoma, but the clinical presentation may not allow differentiation from a subdural hematoma. The possible causal relation between the asymptomatic spinal meningioma, the anticoagulant therapy, and the formation of the subdural hematoma is discussed.

Topics: Female; Hematoma, Subdural; Humans; Meningeal Neoplasms; Meningioma; Middle Aged; Spinal Cord Neoplasms; Warfarin

Topics: Adolescent; Diagnosis, Differential; Female; Fetal Diseases; Hematoma, Subdural; Humans; Hydrocephalus; Pregnancy; Warfarin

Topics: Adolescent; Female; Fetal Diseases; Hematoma, Subdural; Humans; Infant, Newborn; Nose; Pregnancy; Teratogens; Warfarin

A case of spontaneous posterior fossa subdural hematoma secondary to anticoagulation therapy with definitive diagnosis made by vertebral angiography is reported. Vertebral angiographic findings are illustrated and demonstrate primarily mass effect from posterior compartment of posterior fossa and avascular area. Carotid angiography did not show hydrocephalus. A review of the literature was made and this appears to be the first reported case in which a posterior fossa subdural hematoma has been diagnosed by vertebral angiography.

Topics: Adult; Cerebral Angiography; Cranial Fossa, Posterior; Hematoma, Subdural; Humans; Vertebral Artery; Warfarin

Multiple chemical and coagulation determinations were undertaken on the subdural hematoma fluid from the reformed effusions of two patients. It was found that plasma or blood repeatedly reentered the subdural cavity. Coagulation studies compared the in vitro effects of subdural fluid with those of cerebrospinal fluid, serum, and a buffer control. Despite some chemical differences, the subdural fluids from both patients behaved similarly by (1) accelerating the intrinsic clotting system, (2) producing defective clot formation, and (3) accelerating the fibrinolytic system. It is presumed that these continuous hemostatic-fibrinolytic alterations, acting in the subdural sac, may have important implications in the growth and reformation of subdural hematomas, and a hypothesis of the mechanisms involved is presented.

Topics: Aged; Blood Coagulation; Blood Coagulation Tests; Blood Proteins; Erythrocyte Count; Female; Fibrinolysis; Hematoma, Subdural; Humans; Male; Middle Aged; Plasminogen; Recurrence; Thrombelastography; Time Factors; Warfarin

Topics: Acenocoumarol; Hematoma, Subdural; Humans; Male; Middle Aged; Myocardial Infarction; Warfarin

Topics: Aged; Blood Pressure Determination; Brain Abscess; Brain Neoplasms; Cerebral Hemorrhage; Dicumarol; Female; Follow-Up Studies; Hematoma, Subdural; Humans; Intracranial Embolism and Thrombosis; Male; Prothrombin Time; Warfarin

Topics: Aged; Hematoma, Subdural; Humans; Radiography; Warfarin

Topics: Cerebral Angiography; Cerebral Hemorrhage; Hematoma; Hematoma, Subdural; Humans; Intracranial Hemorrhages; Neurosurgery; Neurosurgical Procedures; Toxicology; Warfarin

Topics: Aged; Anticoagulants; Coronary Disease; Drug Therapy; Hematoma; Hematoma, Subdural; Humans; Phenindione; Toxicology; Warfarin