Xray Vision: Headache - Answer

Congratulations to ablumenberg! While your answer wasn’t complete, you were the only one to submit an answer, so, you win money (or a gift card)!

To recap:

An 88 yo M on aspirin and PLAVIX is BIBEMS for headache and vomiting the day after falling out of his chair and bumping his head on the floor. See the whole post HERE.

CT scan showed:

View post on imgur.com

Interpret the Image

ablumenberg hit the nail on the head!

Acute right subdural hematoma with collections along the midline falx, along the right convexity and extending into the right tentorium. The hemorrage measures 1.5cm at maximum. Along the right tentorium the maximum measurement is 1.7cm AP. There is a small acute hemorrhage in the pre-pontine space. There is 6mm of midline shift.

Other than consulting other services, what is your management?

Obviously, neurosugery must be involved. But what can we do in the mean time?

Reverse anticoagulation – in this case, give platelets to reverse aspirin and Plavix.
Keep the head of the bed elevated.
Control blood pressure, SBP goal 140 (frequently with nicardipine).
Place an A-line. This is one of those times it’s actually important emergently.

When neurosurgery says they don't want to operate, I should push for them to operate or transfer, right?

Neurosurgery will often say that in this patient with GCS 15 and no focal deficits, conservative management is a valid option. However, guidelines from 2006 suggest operative evacuation of hematomas >10mm or >5mm midline shift, both of which this patient has. Also given the poor platelet function and acute appearing bleed, this patient is high risk for ongoing hemorrhage and herniation. Frequent neurochecks looking for any change are mandatory. This is a good time to have a good relationship with neurosugery. Have a discussion and advocate for your patient.

References:

Uptodate.com

Bullock, M. R., et al. (2006). “Surgical management of acute subdural hematomas.” Neurosurgery 58(3 Suppl): S16-24;

Bio
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jberkowitz

Dr. Berkowitz is an Emergency Medicine Resident at SUNY-Downstate Medical Center/Kings County Hospital.

Latest posts by jberkowitz (see all)

Xray Vision: Headache – Answer - December 11, 2015
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1 Comment

iandesouza · December 12, 2015 at 7:23 am

Keep in mind that transfusing platelets should be thought of as a “throwing everything but the kitchen sink”-type strategy.

From: Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, et al. Platelet Transfusion: A Clinical Practice Guideline From the AABB. Ann Intern Med. 2015;162:205-213. doi:10.7326/M14-1589

Recommendations
Recommendation 6: The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous).

Quality of evidence: very low; strength of recommendation: uncertain.

Evidence Summary
Five observational studies (n = 635) examined clinical outcomes among patients receiving antiplatelet agents who present with traumatic brain injury (Appendix Table 11) (56). One study reported a greater mortality rate for patients who received transfusions with platelets (relative risk, 2.4 [CI, 1.2 to 4.9]) (57), and a second study reported a lower mortality rate for patients receiving platelets (relative risk, 0.21 [CI, 0.05 to 0.95]) (58). Three studies showed no significant effect on mortality rates when patients received transfusions with platelets (59–61). One additional observational study (n = 88) reported that patients with traumatic brain injury and moderate thrombocytopenia (50 × 109 to 107 × 109 cells/L) who were transfused with platelets had poorer survival than those who were not transfused with platelets (62). In all of these studies, it was not possible to establish a causal relationship between platelet transfusion and clinical outcomes, and confounding by indication was possible.