Management of chronic subdural hematoma in patients treated with anticoagulation.

BACKGROUND: The diffusion of the surgical technique of cardiac valve replacement with metallic prostheses, as well as bypass graft in the arterial occlusive disease of the lower extremities, both requiring permanent oral anticoagulation, has increased the number of patients affected by chronic subdural hematoma that can be diagnosed at an earlier stage of this disease with the advent of the CT. METHODS: The records of seven patients with mean GCS = 14.2 and mean clinical grade = 1.85 affected by chronic subdural hematoma and in treatment with anticoagulants were examined retrospectively. All the patients underwent subtemporal craniectomy plus closed drainage or burrhole(s) plus closed drainage after immediate correction of hypocoagulability by administration of vitamin K and fresh frozen plasma and normalization of PA by calcium heparin. RESULTS: Outcome was good for all the patients except one who died because of cerebral herniation due to massive solid subdural hematoma during extracorporeal dialysis. Complications included: intracerebral hemorrhage, solid subdural hematoma, slow brain reexpansion, subdural collection reaccumulation and cerebral embolism. Three patients required re-operation. Mean duration of hospital stay was 18 days with range from 7 to 24 days. CONCLUSIONS: Basing on this retrospective study and the proposed pathophysiology, the guidelines for optimal management of this subgroup of patients are proposed. Recommendations include the immediate correction of hypocoagulability, the appropriate surgical technique and the cautious conversion to oral anticoagulation as well as the appropriate timing of such conversion.