The dangerous gamble of heparinization within two weeks of nonoperative traumatic acute subdural hematoma in patients with increased stroke risk: A case series

Background: In traumatic acute subdural hematoma (aSDH) management, systemic anticoagulation is contraindicated, particularly during the first 2 weeks. We present two cases of patients with nonoperative aSDH whose stroke risk led to heparinization within 2 weeks of the initial hemorrhage and examine their outcomes to illustrate the risks and benefits associated with systemic anticoagulation. Materials and Methods: Two elderly males, on warfarin at baseline who developed traumatic nonoperative aSDH were heparinized within 2 weeks of aSDH onset. Results: One patient showed a decreased SDH volume on Day 19. The second patient developed sudden onset headache with fixed/dilated pupils on Day 5. In this patient, a CT scan of the brain revealed marked enlargement of the aSDH from 0.9 to 2.4 cm with midline shift of 1.5 cm, and uncal herniation that was incompatible with life. Conclusion: Heparinization within two weeks of aSDH may cause SDH enlargement resulting in rapidly fatal neurologic deterioration. Further study is needed to more definitively address this issue.