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Postoperative Anticoagulation for a Patient with Surgically Treated
SDH and Intermittent Atrial Fibrillation
The patient is a 77-year-old
male on warfarin treatment with a history of symptomatic, intermittent atrial
fibrillation who had fallen out of bed several weeks prior. He presented
to the ER with worsening headaches. While driving he had experienced several
near-accidents, and he had been involved in a fender-bender the day before
admission. In the ER he was awake but intermittently inappropriate.
Neurological examination revealed a right-sided drift in both the upper and lower extremities. He also had a mild expressive aphasia and a right-sided neglect. The CT scan showed a large left-sided isodense and hyperdense subdural hematoma with significant mass effect. The effect of his warfarin was reversed prior to surgical evacuation of his subdural hematoma. The patient did well postoperatively, returning to his normal neurological status within 48 hours of surgery. The postoperative CT scan showed good evacuation of his hematoma.
QUESTION: When and how should anticoagulation be restarted postoperatively in a patient with a surgically treated subdural hematoma and a symptomatic condition (intermittent atrial fibrillation) requiring this treatment?
Considerations
No class I evidence exists to fully answer this question. The risks of thromboembolic
complications related to atrial fibrillation are well documented (5). Significant
work has been done documenting the use of anticoagulation as prophylaxis for
deep venous thrombosis after cranial surgery (1, 2). In addition, there are
many studies on full-dose anticoagulation after orthopedic procedures such
as implantation of a hip prosthesis (4, 7), though clearly the consequences
of postoperative bleeding are different than those after cranial surgery. Two
studies in rats directly studied this question and reached different conclusions
regarding safety and the number of days after surgery to begin anticoagulation
treatment (3, 6).
Deborah L. Benzil, MD, is associate professor at New York Medical College and a neurosurgeon at Westechester Spine and Brain Surgery PLLC, Hartsdale, N.Y.
References
1. Farray D, Carman TL, Fernandez BB Jr.: The treatment and prevention of
deep vein thrombosis in the preoperative management of patients who have neurologic
diseases. Neurol Clin 22(2):423-439, 2004
2. Knovich MA, Lesser GJ: The management of thromboembolic disease in patients with central nervous system malignancies. Curr Treat Options Oncol 5(6):511-517, 2004
3. Laohaprasit V, Mayberg MR: Risks of anticoagulation therapy after experimental corticectomy in the rat. Neurosurgery 32(4):625-628, 1993
4. Lassen MR, Borris LC: Low molecular weight heparin for the prevention of deep vein thrombosis following orthopedic surgery. Curr Opin Pulm Med. 2(4):300-304, 1996
5. Lip GY, Tse HF: Management of atrial fibrillation. Lancet 370(9587):604-618, 2007
6. Schaible KL, Smith LJ, Fessler RG, Rachlin JR, Brown FD, Mullan S: Evaluation of the risks of anticoagulation therapy following experimental craniotomy in the rat. J Neurosurg 63(6):959-962, 1985
7. Yen D: Current concepts in the prevention, detection, and treatment of deep vein thrombosis in total hip and knee replacement. Curr Opin Rheumatol. 4(2):210-215, 1992