Patients on Anticoagulants after a Head Trauma : Is a Negative Initial CT Scan Enough? Report of a Case of Delayed Subdural Haematoma and Review of the Literature
A 66-year-old male presented to the emergency department after a fall and a mild head trauma. He had no history of loss of consciousness or posttraumatic amnesia. The patient had a history of atrial fibrillation and was on acenocoumarol (Sintrom®). His neurological examination was intact. Initial CT scan of the brain was without any sign of intracranial hemorrhage or cranial fracture (). The laboratory workup revealed an International Normalized Ratio (INR) of 2.5. After an 8-hour observation period, he was discharged home.\nForty-eight hours later the patient was transferred to the emergency room with a decreased level of consciousness and vomiting. On neurological examination he had a score of 9/15 on the Glasgow Coma Scale (E2V2M5) and a dilated left pupil unresponsive to light. A CT scan of the brain revealed a large left acute SDH with midline shift (). The patient underwent a craniotomy with evacuation of a large subdural clot. The point of the haemorrhage was some bridging veins to the transverse sinus, which were promptly coagulated. Postoperatively, the left pupil became small and reactive and a CT scan demonstrated complete removal of SDH. The patient progressively improved and one month after the operation he was discharged for further physiotherapy (). Six months later the patient has a Glasgow Outcome Score of 3.