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Is Surgery Advisable When Diagnosed With Subdural Hematoma In Left Frontal Region?
Question: Hi, this is regarding my mom. She is a patient of mitral valve stenosis. Recently she had a blood clot in the valve which led to spending a few days in the hospital. The doctor (cardiologist) has suggested a balloon valvuloplasty or a valve replacement, but that requires the clot to be dissolved first. So she is put on blood thinners for the moment (Warfarin 5 mg).
Two days ago she complained of headache and today the CT scan revealed that there's a "small subdural hematoma in the left frontla region extending 1.6 cm and 0.4 cm in thickness". THe scan also said "acute small heamorrhagic contusion left frontal region".
My question is the right course of treatment at the moment. She is being administered coagulants and plasma and is under observation.
The doctor doesn't seem to be suggesting any surgical procedure at the moment. SHe still has a (not too severe) headache going on at the moment in the hospital.
Two days ago she complained of headache and today the CT scan revealed that there's a "small subdural hematoma in the left frontla region extending 1.6 cm and 0.4 cm in thickness". THe scan also said "acute small heamorrhagic contusion left frontal region".
My question is the right course of treatment at the moment. She is being administered coagulants and plasma and is under observation.
The doctor doesn't seem to be suggesting any surgical procedure at the moment. SHe still has a (not too severe) headache going on at the moment in the hospital.
Brief Answer:
No surgery, restart new anticoagulant.
Detailed Answer:
I read your question carefully and I understand your concern.
It is a difficult situation your mother is in. There is the risk of stroke on one hand and the risk of hematoma expansion from warfarin use on the other. There is no safe decision, whatever/whenever decision is made, it is about choosing the minor evil really, weighing the risk and choosing the minor one. There are no approved guidelines either, there are expert opinions based on experience, but no randomized studies.
Regarding a surgical procedure, I agree with not having one, that is an easy decision judging from that info. The subdural hematoma is only 0.4 cm in thickness, no compression and a surgery wouldn't solve anything only risk more hemorrhage. The hemorrhagic contusion doesn't need any surgery either, only time.
The difficult decision is when to restart anticoagulation, how much to wait. Opinions as I said may vary, from a couple of days to a couple of months, the tendency in recent years has been to delay it more than in the past. The higher the risk of clot complications the higher the risk for stroke. In her situation she has been evidenced to have a formed clot which makes the risk for stroke pretty high.
So my choice would be to restart anticoagulation early, after 7-14 days. Of course before that a control CT is recommended and after she should be monitored for changes in her neurological status which could indicate more bleeding.
One thing I would change though, is not put her into Warfarin, but into one of the newer anticoagulant like apixaban, dabigatran, edoxaban, rivaroxaban. They are at least as efficient as Warfarin while on the other hand studies have shown to have fewer hemorrhagic complications, and especially to have cause clearly fewer intracranial bleeding, so would definitely be the best choice in this case. I am sure the cardiologists are familiar with them as they are becoming more and more popular.
I remain at your disposal for further questions.
No surgery, restart new anticoagulant.
Detailed Answer:
I read your question carefully and I understand your concern.
It is a difficult situation your mother is in. There is the risk of stroke on one hand and the risk of hematoma expansion from warfarin use on the other. There is no safe decision, whatever/whenever decision is made, it is about choosing the minor evil really, weighing the risk and choosing the minor one. There are no approved guidelines either, there are expert opinions based on experience, but no randomized studies.
Regarding a surgical procedure, I agree with not having one, that is an easy decision judging from that info. The subdural hematoma is only 0.4 cm in thickness, no compression and a surgery wouldn't solve anything only risk more hemorrhage. The hemorrhagic contusion doesn't need any surgery either, only time.
The difficult decision is when to restart anticoagulation, how much to wait. Opinions as I said may vary, from a couple of days to a couple of months, the tendency in recent years has been to delay it more than in the past. The higher the risk of clot complications the higher the risk for stroke. In her situation she has been evidenced to have a formed clot which makes the risk for stroke pretty high.
So my choice would be to restart anticoagulation early, after 7-14 days. Of course before that a control CT is recommended and after she should be monitored for changes in her neurological status which could indicate more bleeding.
One thing I would change though, is not put her into Warfarin, but into one of the newer anticoagulant like apixaban, dabigatran, edoxaban, rivaroxaban. They are at least as efficient as Warfarin while on the other hand studies have shown to have fewer hemorrhagic complications, and especially to have cause clearly fewer intracranial bleeding, so would definitely be the best choice in this case. I am sure the cardiologists are familiar with them as they are becoming more and more popular.
I remain at your disposal for further questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Dr. Taka
Thanks a lot for your detailed and informative response. It was very helpful.
It was good to hear that the treatment going on at the moment is what you also generally recommend. One follow up question in this regard. She still had a moderate level headache yesterday and in the night (about 10.5 hours ago, at the time of writing this message), the doctor gave her an injection of Tramadol. At the moment she feels alright (after getting up today), slightly drowsy because of the Tramadol I think.
My question is regarding the timeline of when the headaches decrease/disappear. In general how long do you think it takes before that happens?
One other question, mom has an upcoming travel on July 19th (in 4 days) to see the doctor that is managing her mitral stenosis. She has to take about an hour long flight for that. Do you think it is safe to fly or would you recommend postponing the travel?
Thanks again for your helpful response. The opinion of a neurologist is really valuable at the moment for us.
Thanks
XXXX
Thanks a lot for your detailed and informative response. It was very helpful.
It was good to hear that the treatment going on at the moment is what you also generally recommend. One follow up question in this regard. She still had a moderate level headache yesterday and in the night (about 10.5 hours ago, at the time of writing this message), the doctor gave her an injection of Tramadol. At the moment she feels alright (after getting up today), slightly drowsy because of the Tramadol I think.
My question is regarding the timeline of when the headaches decrease/disappear. In general how long do you think it takes before that happens?
One other question, mom has an upcoming travel on July 19th (in 4 days) to see the doctor that is managing her mitral stenosis. She has to take about an hour long flight for that. Do you think it is safe to fly or would you recommend postponing the travel?
Thanks again for your helpful response. The opinion of a neurologist is really valuable at the moment for us.
Thanks
XXXX
Brief Answer:
Read below.
Detailed Answer:
Thank you for the feedback.
Regarding the headache, if the conditions remains stable with no re-bleed headache should subside gradually over the course of the first week. If it increases in intensity instead a repeat CT scan should be done.
As for the flight, it is generally recommended for a month before flying. Since it is a small hematoma and a short flight that time can be shortened if condition is stable, but still after not even a week I think it s too soon and should be postponed. If that consult is considered necessary I suppose the mitral stenosis treating specialist can be contacted by your doctors, in order for him to make potential additional recommendations.
I would also like to make a correction to my previous answer, because of the enthusiasm there is nowadays about these new oral anticoagulants and their fewer side effects, I hurried into recommending them, but then I remembered that in the case of valvular atrial fibrillation they are not yet approved, the future may hopefully change that, but for the moment studies include mostly nonvalvular atrial fibrillation patients and are not approved for valvular patients, sorry about that, warfarin is still the only option.
I hope to have been of help.
Read below.
Detailed Answer:
Thank you for the feedback.
Regarding the headache, if the conditions remains stable with no re-bleed headache should subside gradually over the course of the first week. If it increases in intensity instead a repeat CT scan should be done.
As for the flight, it is generally recommended for a month before flying. Since it is a small hematoma and a short flight that time can be shortened if condition is stable, but still after not even a week I think it s too soon and should be postponed. If that consult is considered necessary I suppose the mitral stenosis treating specialist can be contacted by your doctors, in order for him to make potential additional recommendations.
I would also like to make a correction to my previous answer, because of the enthusiasm there is nowadays about these new oral anticoagulants and their fewer side effects, I hurried into recommending them, but then I remembered that in the case of valvular atrial fibrillation they are not yet approved, the future may hopefully change that, but for the moment studies include mostly nonvalvular atrial fibrillation patients and are not approved for valvular patients, sorry about that, warfarin is still the only option.
I hope to have been of help.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Doctor Taka
Thanks again for your detailed and helpful reply. Sorry, I have another question:
My mother is being administered plasma. She was also given Tramadol ivy drip last night and today. Today since morning (for about 8-9 hours now), her blood pressure is 90/50, below normal (but stable at that value today).
Do you think this is a side effect of something she is being given?
Thanks
XXXX
Thanks again for your detailed and helpful reply. Sorry, I have another question:
My mother is being administered plasma. She was also given Tramadol ivy drip last night and today. Today since morning (for about 8-9 hours now), her blood pressure is 90/50, below normal (but stable at that value today).
Do you think this is a side effect of something she is being given?
Thanks
XXXX
Brief Answer:
Read below.
Detailed Answer:
You're welcome and please feel free to ask as many questions as you need.
Tramadol can lead to blood pressure fluctuations, but it is a very rare effect. So while doctors should keep that possibility in mind I wouldn't consider it that likely and consider the possibility of her low heart function or the drugs she takes for it, being the cause.
Wishing you and your mother good health.
Read below.
Detailed Answer:
You're welcome and please feel free to ask as many questions as you need.
Tramadol can lead to blood pressure fluctuations, but it is a very rare effect. So while doctors should keep that possibility in mind I wouldn't consider it that likely and consider the possibility of her low heart function or the drugs she takes for it, being the cause.
Wishing you and your mother good health.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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