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Journal of The Association of Physicians of India ■ Vol.

63 ■ August 2015 79

Spontaneous Resolution of Chronic Subdural Haematoma in a


Patient Receiving Anticoagulant Therapy
Shailendra Ratre1, Yadram Yadav 2, Sushma Choudhary3, Vijay Parihar1

considerable difficulty in diagnosis by


Abstract CT scan. MRI could help in making the
diagnosis of such lesion. 6
Significant chronic subdural hematoma (CSDH) is usually a surgical emergency.
Spontaneous resolution of CSDH has rarely been reported in the literature. We Surgery is generally considered
are reporting a case of spontaneous resolution of CSDH in a patient receiving the treatment of choice for CSDH, but
anticoagulant therapy who had undergone mitral valve replacement surgery. conservative management of CSDH in
some patients on anticoagulant therapy
have been reported in the literature. 7,8
Literature concerning spontaneous
Introduction drug (acenocoumarin) was stopped resolution of CSDH (due to any cause)
and vitamin K was supplemented. with medical treatment consists of

C hronic subdural hematoma (CSDH)


is a common type of intracranial
hemorrhage and is predominantly
As patient was neurologically stable,
she was kept under close observation
on decongestants and steroids
small case series and very few clinical
observations. 9 Reports focusing on
spontaneous resolution of CSDH
seen in the elderly. The most common (Dexamethasone 4 mg four times in patients receiving anticoagulant
cause of this lesion is head injury, a day) and surgery was postponed th era p y i s very s p a rse . 7,8 T o t a l 1 5
but several predisposing factors until normalization of coagulation reports including 286 patients are
such as coagulopathy, alcoholism, profile which was 10 days. Patient published on non-surgical treatment
cerebrospinal fluid shunt procedures, improved symptomatically in terms of of all types of CSDH till now. 9
vascular malformations, seizure headache and her vomiting subsided Va r i o u s t h e o r i e s h a v e b e e n
disorders, and metastatic tumors must c o m p l e t e l y . R e p e a t C T h e a d wa s suggested to explain the mechanisms
be ruled out. Response to surgery planned before surgery which revealed of formation and resolution of CSDHs.
h a s b e e n ve r y s a t i s f a c t o r y a n d i s almost complete resolution of CSDH Corticosteroids inhibited the formation
generally considered the treatment and brain oedema with total correction of protein-permeable membrane,
of choice. 1 Spontaneous resolution of midline shift (Figure 2). Patient was d e c r e a s i n g t h e s i z e o f C S D H . 10
of CSDH has rarely been reported discharged and at 2 months follow up Maturation of the neomembrane and
in the literature, and its mechanism patient is doing well. stabilization of the neovasculature
has not been fully investigated. We might eventually result in spontaneous
are reporting an extremely rare case Discussion
resolution. 11 In our case steroids may
of spontaneous resolution of CSDH have played role in resolution. CSDHs
Chronic subdural hematoma
in a patient receiving anticoagulant with idiopathic thrombocytopenic
(CSDH) is one of the most common
therapy, presented with symptoms purpura may resolve spontaneously
neurosurgical conditions. The trauma
of raised intracranial pressure and or with medical treatment. Surgery
and antithrombotic therapy are the
midline shift on imaging. might be deferred except in emergency
most frequent risk factors.2 The
incidence of CSDHs in patients on conditions or in patients with
Case Report
warfarin is reported as between 21% neurological deficit. Close neurological
A 40-year-old woman presented and 36%. Majority of spontaneous and radiological observation along
with 2 months history of holocranial CSDHs (75%) patients are found to with the medical treatment could be
headache, which had increased in b e o n a n t i c o a g u l a n t s . 3 , 4 B e r wa e r t s appropriate in patients with normal
severity over the past few days, with et al found hypertension, an INR neurological findings. 12 Early surgery
vomiting. She was a known case of on admission of more than 4.5, and without correction of coagulopathy
rheumatic heart disease with mitral the duration of anticoagulation, as is a risk factor in the recurrence. 13
valve stenosis and underwent mitral significant risk factors for intracranial Nontraumatic SDHs or hygromas
valve replacement 1 year back. She was hemorrhages in patients receiving in infants can often experience
on acenocoumarin as anticoagulant. oral anticoagulant therapy. 5 CT with significant resolutions within several
On examination, she was conscious, contrast and magnetic resonance months without surgical treatment. 16
oriented with no neurological imaging are diagnostic of CSDH. Spontaneous resolution of post-
deficit. Fundus examination showed Bilateral isodense CSDH may cause traumatic CSDH in patients without
papilledema. CT head revealed a large
left fronto-parietal CSDH with brain
oedema, mass effect and midline shift 1
Assistant Professor, 2Assosciate Professor, Dept. of Neurosurgery, 3Senior Resident, Department of Medicine, NSCB Medical
(Figure 1). Her international normalized College, Jabalpur, Madhya Pradesh
ratio (INR) was of 10. Anticoagulant Received: 30.05.2014; Revised: 12.07.2014; Accepted: 15.07.2014
80 Journal of The Association of Physicians of India ■ Vol. 63 ■ August 2015

Fig. 1: CT scan of patient showing left fronto-parietal chronic Fig. 2: Repeat CT scan showing almost complete resolution of
subdural haematoma with midline shift haematoma with a small residual part

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