The patients of traumatic intracranial hemorrhage (TICH) with preinjury antithrombotic therapy are difficult to treat because of two conflicted factors. We experienced two cases, those clinical courses seemed to be unique and useful when considering a management strategy for these patients.
Case 1: A 67 year-old woman suffered from severe head injury by falling down from upstairs. The patient's Glasgow Coma Scale (GCS) score was 5 at transfer to our acute care center. Initial brain computed tomography (CT) scan demonstrated left acute subdural hematoma, and she received emergent decompressive craniectomy and evacuation of hematoma. She also suffered from acute myocardial infarction (AMI) intraoperatively and received percutaneous coronary intervention (PCI) immediately after craniotomy operation, and antiplatelet therapy (APT), aspirin, was started. Twenty-four hours later, she presented anisocoric pupil (left > right) and brain CT scan revealed growth of left temporal contusional hematoma and impending uncal herniation, following emergent left temporal lobe resection including contusional hematoma. Additionally, she received 2nd PCI with BMS stent placement and dual APT (aspirin + clipidogrel) was started six days after head injury. After that, she recovered with dual APT, having no hemorrhagic and ischemic events.
Case 2: A 76 year-old man was transfered from near hospital to our center because of acute subdural hematoma in spite of no apparent episode of head injury. He had received anticoagulation therapy (ACT) for long periods and his PT-INR was over 14 at transfer. Conservative therapy with rapid injection of Vitamin K was performed, then, there was no enlargement of intracranial hematoma. However, he presented left hemiparesis two days later, and Magnetic Resonance Imaging (MRI) demonstrated right temporo-occipital cortical infarction and also right internal capsule infarction. The mechanism of this ischemic event was unclear, maybe not a cardiogenic embolism, but poor control of ACT was considered to be one of the causes of this infarction.
Intensive systemic management, especially strict control of blood pressure within acute stage, at intensive care unit (ICU) seemed to lead to good result in case 1. Case 2 indicated that treatment of traumatic injury with poor control of ACT became more difficult and complicated. The important step in the management of TICH with preinjury antithrombotic agents is thought to be an exact evaluation and assessment of hemorrhagic and thrombotic factors. Additionally, even though when unexpected emergent event occur, for example hematoma enlargement or cerebral ischemic event, prompt and reasonable treatment, we think, will lead to better clinical outcomes.