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Case Report | DOI: https://doi.org/10.31579/2690-1919/280
Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
*Corresponding Author: Douglas Rappaport. Department of Emergency Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA.
Citation: Douglas Rappaport, Kartik Mangipudi, Thomas M. Polveroni, Wayne Martini. (2022). Delayed Subarachnoid Hemorrhage in A Patient on Warfarin with Blunt Head Trauma, J. Journal of Clinical Research and Reports, 12(2) DOI: 10.31579/2690-1919/280
Copyright: © 2022 Douglas Rappaport. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 27 October 2022 | Accepted: 10 November 2022 | Published: 23 November 2022
Keywords: subarachnoid hemorrhage; blunt head trauma; emergency department
Closed head trauma in anticoagulated patients is an increasing common presentation to Emergency Department (ED). Within this population, there is a subset of patients who present with delayed intracranial haemorrhage, typically resulting in subdural or parenchymal bleeds, with negative initial non-contrast head CT.
Closed head trauma in anticoagulated patients is an increasing common presentation to Emergency Department (ED).[1] Within this population, there is a subset of patients who present with delayed intracranial haemorrhage, typically resulting in subdural or parenchymal bleeds, with negative initial non-contrast head CT. [1,2,3] This paper presents a rare case of delayed traumatic pontine perimesencephalic sub-arachnoid haemorrhage in a patient on warfarin.
A 76-year-old gentleman on therapeutic warfarin for atrial fibrillation presented to the ED following a witnessed ground level fall with trauma to the occiput. Initial non-contrast head CT performed within 6 hours of initial injury was negative for any acute pathology, and the patient was subsequently discharged home from the ED. The patient had a progressively worsening headache and represented with new focal neurological deficits including polycranial neuropathy, 3 days after onset of trauma. Repeat non-contrast CT scan was notable for a pontine perimesencephalic subarachnoid haemorrhage with no evidence of aneurysm on cerebral angiogram.
There is variability in opinion with regard to optimal management of anticoagulated patients who sustain closed head trauma with initial negative non-contrast head CT. [4,5] It is well documented in the literature that a small fraction of these patients develops delayed intracranial haemorrhage with some requiring Neurosurgical intervention. [2,3,4] There is minimal literature documenting delayed traumatic sub-arachnoid haemorrhages, making this case unique. Based on this case, we advocate for consideration of limited MRI scan in high risk patients with suspected posterior fossa pathology and or extended periods of observation and provider follow up within 24 hours to assess need for repeat imaging.[5,6,7] Certainly more research is required in this area to illuminate new management options.
Figure 1: Non-contrast CT head axial and sagittal views upon first presentation to the Emergency Department demonstrating no evidence of parenchymal or extra-axial haemorrhage
Figure 2: Non-Contrast CT head axial and sagittal views upon second presentation to the Emergency Department 3 days after head trauma demonstrating new perimesencephalic pontine sub-arachnoid haemorrhage with trace intraventricular extension
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