Delayed posttraumatic acute subdural hematoma in elderly patients on anticoagulation

OBJECTIVE: To discuss delayed acute subdural hematoma (DASH), a relatively neglected entity, and to emphasize the potentially elevated risk for DASH among elderly, anticoagulated mild traumatic brain injury (TBI) patients. METHODS: The authors reviewed clinical and radiological data for four patients who had normal neurological examinations and normal computed tomographic scans after mild TBI, and who subsequently developed DASH and deteriorated rapidly. RESULTS: The patients included two men and two women, aged 65 to 86 years, who presented to the emergency department after mild TBI between January 2002 and June 2004. All were treated with chronic anticoagulation or anti-aggregation therapy. They deteriorated owing to DASH from 9 hours to 3 days after TBI. Three of the four patients underwent craniotomy for evacuation of their hematomas. One patient, who suffered only focal neurological deficit, was treated conservatively, and her hematoma gradually resolved. Two patients died and two reached Glasgow Outcome Scores of 3 and 4 after extended inpatient rehabilitation. CONCLUSION: A suspicion of DASH should be raised in elderly, anticoagulated, mild TBI patients, including those who present to the emergency department with Glasgow Coma Scores of 15 and normal computed tomographic scans after injury. Based on our experience, we recommend that elderly, anticoagulated mild TBI patients should be admitted for 24 to 48 hours of observation after injury.