Intracranial Hemorrhage in a Patient with Double Valve Replacement: A Balancing Act

Keywords

double valve replacement - warfarin - intracranial hemorrhage

Introduction: Vitamin K antagonist “warfarin” is recommended in patient with prosthetic heart valve with aim to maintain international normalized ratio (INR) of 2.5. Intracranial hemorrhage is a dreaded complication in these patients. Optimum correction of anticoagulation to provide a window to allow neurosurgery while preventing valve thrombus is a delicate balancing act.

Methodology/Description: A 31-year-old patient, known case of rheumatic heart disease with aortic and mitral valve replacement done a month back, presented with emesis for a day and headache and fever. Computed tomography (CT) scan showed a right frontoparietal subdural hematoma and midline shift. The INR was 7.7 and 300 mL fresh frozen plasma was administered to correct it to INR 1.8. During the emergency decompression craniotomy, the main concerns were bleeding, thromboembolism, hemodynamic instability, valvular dysfunction, and infective endocarditis. Balanced anesthesia was used with invasive monitoring and transesophageal echocardiography. Intraoperative course was uneventful and patient was extubated. Intravenous heparin was administered. On day 2, CT suggested hematoma with midline shift. Patient was taken for reexploration with repeat blood and plasma transfusions. After extubation, a single episode of convulsions occurred on the fifth day. Anticonvulsants were started. CT scan showed increased size of extraaxial hematoma. A third decompression craniotomy followed. Injection low-molecular-weight heparin (LMWH) 0.4 mg subcutaneous twice a day started. At present, patient is stable and shifted to ward.

Conclusion: Valve replacement patients are at high risk of intracranial hemorrhage due to anticoagulation. Appropriate management of anticoagulation is essential to ensure functioning of valve as well as prevent bleeding at other sites.

• References

• 1 Panduranga P, Al-Mukhaini M, Al-Muslahi M, Haque MA, Shehab A. Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding.. World J Cardiol 2012; 4 (03) 54-59