Nontraumatic subdural hematoma following triple antithrombotic therapy plus heparin after PTCA and coronary stent implantation

A 80-year-old man was admitted with unstable angina. Percutaneous transluminal angioplasty and stent implantation was performed into the LAD. The following day the patient continued to suffer from recurrent cardiac ischemia and transluminal stent placement into the dominant right coronary artery was performed. On day 1 after stent placement the patient developed left sided hemiparesis and decreased conciousness. A brain CT scan (Figure) revealed large right sided subdural hematoma with blood extending into the interhemisheric space.

The patient received triple antithrombotic therapy with aspirin 100mg per day, Clopidogrel 300mg on day one and 75mg from day two on and tirofiban (0,4ug/kg/min for 30min, followed by a continuous infusion of 0,1ug/kg/min) plus heparin. During both angioplasty he received an intravenous bolus of 7,500 IU, followed by 800–1,000 IU per hour over 24 hours until the intravascular sheath was withdrawn.

The patient had no history of dementia, stroke, bleeding disorder, alcohol abuse, liver disease or head trauma. Creatinin and urea levels as well as thrombocyte counts were repeatedly in the normal range. No identifiable trauma was present during the hospital treatment and the patient did not show physical signs of external trauma.

A craniotomy was performed and the hemotoma evacuated. The patient was discharged for further neurological rehabilitation 16 days later. At hospital discharge the hemiparesis was persistent.

In complex cardiological cases such as this, it is now standard care to provide triple antithrombotic treatment plus periprocedural intravenous heparin to reduce myocardial ischemia before and after PTCA and coronary stent placement .

Recent studies support this approach and show little or no evidence for spontaneous intracranial hemorrhage. However, patients in these studies are younger than our patient. Patients with dementia are excluded from these studies.

The risk of spontaneous subdural hemorrhage increases with age and the presence of dementia and cognitive decline .

This case illustrates an increased risk of spontaneous intracranial hemorrhage in the elderly especially following antithrombotic medications.