A "Small" Subdural in an Anticoagulated Elderly Patient
A 79-year-old woman arrives three hours after a ground-level fall at home in which she struck her occiput on a doorframe. She takes apixaban for atrial fibrillation and daily aspirin. She denies loss of consciousness, but her husband reports one episode of vomiting in the car and she now has a mild headache. GCS 15, pupils equal and reactive, no focal deficits. HR 78, BP 156/84, RR 16, SpO2 97%. A 3 cm occipital hematoma is present. CT shows a 5 mm left frontal acute subdural hematoma with effaced sulci and no midline shift. Your hospital has no neurosurgery; the trauma center is 2.5 hours by ground and 40 minutes by air, but low ceilings are currently grounding rotor-wing transport. Her last apixaban dose was 12 hours ago.
1. What risk factors drive your disposition decision, and how do you weigh transfer against local observation?
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What matters: she is anticoagulated and on an antiplatelet, is elderly, has vomited, and has a radiographically visible subdural. A 5 mm SDH with GCS 15 is a time bomb, not a reassuring scan. Anticoagulated patients with any intracranial hemorrhage have substantially higher rates of delayed expansion and deterioration, and the first hours carry the highest risk. Age-related atrophy lets a hematoma accumulate before herniation, so GCS will not be an early warning.
Weighing the options:
- Local observation is defensible only with hourly neuro checks, a repeat CT protocol at 6–12 hours (sooner with any change), reversal already started, and the ability to intubate and manage a herniating patient.
- Transfer is the safer disposition because she may need reversal monitoring, ICP management, and possible craniotomy.
- Weather is currently grounding air. Do not let it delay definitive care: request rotor-wing for when ceilings lift, but start ground transfer if the air ETA is not clearly better. A deteriorating patient two hours into a ground transfer is worse than a flight arranged an hour earlier. Speak directly with the receiving neurosurgeon now and document that shared decision.
2. How do you manage her anticoagulation, and what do you do about the aspirin?
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Apixaban: last dose 12 hours ago; check creatinine clearance, since apixaban clearance is renal-dependent. Options are andexanet alfa if available and approved at your center, or off-label 4-factor PCC per institutional protocol (commonly ~50 units/kg). The evidence for PCC in factor Xa inhibitor reversal is weaker, but it is what most centers have. Call the receiving center and pharmacy before administering, and obtain a follow-up CT after reversal to establish a new baseline.
Aspirin: there is no acute reversal agent, and platelet transfusion is not indicated outside of intracranial surgery or bleeding refractory to other measures. Note it as additive bleeding risk; do not chase it.
Also: hold further apixaban, keep SBP roughly under 140–160 to limit expansion, and avoid hypotension. Do not order or interpret an INR for monitoring - it does not reflect apixaban effect and should not be used to guide reversal.
3. Ninety minutes into the wait she reports a worsening headache, vomits again, and her right pupil is 4 mm and sluggish while the left is 2 mm. Outline your actions in order.
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This is herniation until proven otherwise.
- Airway and ventilation: intubate if GCS is falling; preoxygenate, maintain MAP, and avoid hypotension during induction. Brief hyperventilation to a PaCO2 of 30–35 mmHg as a bridge - minutes, not hours.
- Osmotherapy: 3% hypertonic saline 250 mL bolus (or mannitol 1 g/kg if sodium and blood pressure permit). Do not wait for imaging.
- Position: head of bed 30°, head midline, loosen any collar.
- Reverse the anticoagulant now. The calculus shifts from "discuss with the receiving center" to "give it."
- Repeat CT immediately to size the hematoma and assess midline shift; call neurosurgery directly, not only the transfer center.
- Transport: declare an emergency, request air and ALS ground simultaneously, and do not let her board in the ED waiting for a bed.
- Avoid anything that drops cerebral perfusion pressure - no reflexive treatment of her hypertension to a "normal" number, no hypoxia, no hypercarbia.