Anticoagulation therapy a risk factor for the development of chronic subdural hematoma
Introduction
The incidence of chronic subdural hematoma (CSDH) has been reported to be 3.4 per 100,000 in patients younger than 65 years of age, and 8–58 per 100,000 in those older than 65 years [1]. Because of the continuing rise of life expectancy in the western world [2] and the increasing use of anticoagulants and antiplatelet aggregation agents (AAA) [3], [4], [5], the incidence of CSDH is expected to rise. This underlines the importance for an improved understanding of the relation between the development of CSDH and the use of anticoagulants and AAA.
Treatment of CSDH depends on clinical symptoms and the size of the hemorrhage. Three main surgical techniques exist for the evacuation of CSDH: burr-hole craniostomy (BHC), twist-drill craniostomy (TDC) and craniotomy. BHC is associated with a lower rate of recurrence [1] and lower rate of severe complications compared to TDC and craniotomy [6]. The use of closed-system drainage following BHC has been reported to further reduce recurrence rate and mortality [7].
The role of anticoagulants and AAA in the development and recurrence of CSDH is unclear [3], [5], [8], [9]. These agents are widely used to reduce the risk of both venous and arterial thromboembolic events in patients with prosthetic heart valves and in others diagnosed with atrial fibrillation, cerebrovascular disease, ischemic heart disease and peripheral arteriosclerosis [10]. Patients suffering from CSDH while recieving anticoagulants and/or AAA have their medication discontinued in order to minimize the risk of further hematoma expansion. In emergency situations where immediate intervention is required, rapid reversal of anticoagulation is needed. Reversal of warfarin is generally accomplished by infusion of fresh frozen plasma (FFP), prothrombin complex concentrate or vitamin K and the reversal of AAA can be met by platelet transfusion [11].
The aim of this study was to investigate associations between treatment with anticoagulants and AAA, and the development and recurrence of chronic subdural hematomas.
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Materials and methods
A retrospective study was performed over a 6-year period between January 2006 and November 2011 at the Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark. Two hundred and eighty-four patients who had surgical evacuation for CSDH were identified. Exclusion criteria comprised hygromas but also ventriculoperitoneal shunts, arachnoid cysts, CNS-lymphomas, acute myeolid leukemia with chemotherapy, since these have been reported to be direct causes of non-traumatic CSDH [12], [13], [14],
Results
The study included a total of 239 patients, of which 171 were males (72%) and 68 were females (28%) in the age range of 28–97 years. Mean age was 71.8 years (median 72); 70.7 years among males (median 71) and 74.8 years among females (median 77,5). A hundred and four patients (44%) received pre-morbid anticoagulant and/or AAA therapy. Seventy-seven of these (74%) were males and 27 (26%) were females. Warfarin was used by 34 patients (14%), AAA by 63 patients (26%) and warfarin combined with AAA
Discussion
In this study we have found a significantly greater prevalence of patients receiving anticoagulants and/or AAA therapy in the non-trauma group compared to the trauma group. These are very important findings because of the steadily increasing use of anticoagulants and AAA-therapy combined with the continuing rise of life expectancy, we assume the incidence of non-traumatic CSDH's to rise. Furthermore, this is to the best of our knowledge, the largest retrospective study focusing on traumatic and
Conclusion
Anticoagulant- and/or AAA-therapy is more prevalent among non-traumatized CSDH patients. This underlines the importance of awareness for the potential risk of CSDH development among older people with cardiovascular co-morbidity.
Conflict of interest
There are no conflict of interest for the study.
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