Deteriorating acute subdural haematoma on apixaban
A 76-year-old man is brought to the emergency department after a fall from standing at home. He takes apixaban 5 mg twice daily for atrial fibrillation and had his last dose 12 hours ago. His eGFR is 55 mL/min/1.73 m². Initial Glasgow Coma Scale is 15, and he has no focal deficit. He vomited once. A non-contrast CT scan shows a 5 mm left acute subdural haematoma with 2 mm midline shift and effacement of the left lateral ventricle. He is admitted for observation. Six hours later, his Glasgow Coma Scale falls to 13 (E3 V4 M6), he vomits again, and his right pupil becomes 4 mm compared with 3 mm on the left, with a sluggish reaction. Repeat CT shows the subdural haematoma has enlarged to 13 mm with 6 mm midline shift and a new 1.5 cm contusion in the left frontal lobe. The neurosurgical theatre is available, and the family asks whether surgery is worthwhile because he is elderly and anticoagulated.
1. What immediate medical measures are required before and during transfer to theatre?
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This is a time-critical traumatic brain injury with neurological deterioration and likely uncal herniation. Immediate measures are:
- Airway protection: his GCS is 13 and falling; intubate if there is any further decline, vomiting, or inability to protect the airway. Avoid hypotension and hypoxia.
- Reverse apixaban urgently. If andexanet alfa is available, give it according to the local protocol. If not, give four-factor prothrombin complex concentrate 50 U/kg and consider tranexamic acid. Vitamin K is not an effective reversal agent for a direct factor Xa inhibitor. Do not wait for the INR, which may be normal.
- Check full blood count, coagulation screen, fibrinogen, and renal function; correct any platelet or fibrinogen deficiency.
- Elevate the head, control pain and agitation, and keep systolic blood pressure adequate for cerebral perfusion while avoiding hypertension that worsens bleeding.
- Treat raised intracranial pressure with hypertonic saline or mannitol if the pupil remains dilated, and involve neurosurgery immediately.
- Crossmatch blood and take the patient to theatre as soon as reversal has been given; surgery should not be delayed until coagulation tests normalise.
2. Does this patient meet indications for craniotomy and evacuation? Explain your reasoning.
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Yes. He meets surgical indications for acute subdural haematoma evacuation: clot thickness greater than 10 mm, midline shift greater than 5 mm, a fall in GCS, new vomiting, and an ipsilateral pupillary dilation. The new frontal contusion adds to the mass effect. Age and anticoagulation are not absolute contraindications. Without evacuation, the trajectory is likely to be fatal, whereas surgery offers a chance of survival, although neurological recovery may be limited.
I would perform a craniotomy, not a burr-hole drainage, because the clot is thick, partly organised, and associated with contusion and brain swelling. The bone flap may need to be left out if there is severe swelling. I would place an intracranial pressure monitor and continue haemostatic support. The family should be given a realistic but not nihilistic prognosis: surgery can relieve the mass effect and prevent herniation, but outcome depends on the underlying brain injury, age, and comorbidities. A do-not-attempt-resuscitation discussion can occur alongside, not instead of, urgent decompression.
3. When and how would you restart anticoagulation?
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I would not restart apixaban acutely. The immediate priority is haemostasis. I would wait until there is clinical and radiological stability, usually after at least 24–48 hours and often longer, with a repeat CT showing no expansion and stable neurological status. The decision is a balance between recurrent intracranial bleeding and thromboembolic stroke from atrial fibrillation.
I would involve neurology, cardiology, and haematology. In a patient with high stroke risk and a large traumatic haematoma, restarting a direct oral anticoagulant is often deferred for several weeks; if anticoagulation cannot be safely restarted, left atrial appendage occlusion may be considered. Blood pressure should be controlled, falls risk addressed, and the family involved. There is no single correct timing, so the reasoning and risk discussion should be documented. Antiplatelet therapy would only be added if there were a separate compelling indication.