Coagulopathy and inhospital deaths in patients with acute subdural hematoma

Clinical article

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Acute subdural hematoma (SDH) is one of the most lethal forms of intracranial injury; several risk factors predictive of a worse outcome have been identified. Emerging research suggests that patients with coagulopathy and intracerebral hemorrhage have a worse outcome than patients without coagulopathy but with intracerebral hemorrhage. The authors sought to determine if such a relationship exists for patients with acute SDH.


The authors conducted a retrospective analysis of consecutive patients admitted to a neurosciences intensive care unit with acute SDH over a 4-year period (January 1997–December 2001). Demographic data, laboratory values, admission source, prior functional status, medical comorbidities, treatments received, and discharge disposition were recorded, as were scores on the Acute Physiology, Age, and Chronic Health Evaluation III (APACHE III). Coagulopathy was defined as an internal normalized ratio > 1.2 or a prothrombin time ≥12.7 seconds. Univariate and multivariate analyses were performed on 244 patients to determine factors associated with worse short-term outcomes.


The authors identified 248 patients with acute SDH admitted to the neurointensive care unit during the study period, of which 244 had complete data. Most were male (61%), and the mean age of the study population was 71.3 ± 15 years (range 20–95 years). Fifty-three patients (22%) had coagulopathy. The median APACHE III score was 43 (range 11–119). Twenty-nine patients (12%) died in the hospital. Independent predictors of inhospital death included APACHE III score (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.4–13.4, p = 0.011) and coagulopathy (OR 2.7, 95% CI 1.1–7.1, p = 0.037). Surgical evacuation of acute SDH was associated with reduced inhospital deaths (OR 0.2, 95% CI 0.1–0.6, p = 0.003).


Coagulopathy is independently associated with inhospital death in patients with acute SDH. Time to treatment to correct coagulopathy using fresh frozen plasma and/or vitamin K was prolonged.

Abbreviations used in this paper: APACHE III = Acute Physiology, Age, and Chronic Health Evaluation III; CI = confidence interval; FFP = fresh frozen plasma; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; ICU = intensive care unit; INR = international normalized ratio; LOS = length of stay; NICU = neurosciences ICU; OAT = oral anticoagulation therapy; OR = odds ratio; PCC = prothrombin complex concentrate; PT = prothrombin time; rFVIIa = recombinant activated factor VIIa; SD = standard deviation; SDH = subdural hematoma.

Article Information

Address correspondence to: Jose I Suarez, M.D., Department of Neurology, Baylor College of Medicine, One Baylor Plaza, NB 302, Houston, Texas 77030. email:

© AANS, except where prohibited by US copyright law.



  • 1

    Abraham EReinhart KOpal SDemeyer IDoig CRodriguez AL: Efficacy and safety of Tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis: a randomized controlled trial. JAMA 290:2382472003

  • 2

    Broderick JPBrott TGDuldner JETomsick THuster G: Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 24:9879931993

  • 3

    Brody DLAiyagari VShackleford AMDiringer MN: Use of recombinant factor VIIa in patients with warfarin-associated intracranial hemorrhage. Neurocrit Care 2:2632672005

  • 4

    Depreitere BVan Calenbergh Fvan Loon J: A clinical comparison of non-traumatic acute subdural haematomas either related to coagulopathy or of arterial origin without coagulopathy. Acta Neurochir (Wien) 145:5415462003

  • 5

    Dickneite G: Prothrombin complex concentrate versus recombinant factor VIIa for reversal of coumarin anticoagulation. Thromb Res 119:6436512007

  • 6

    Flibotte JJHagan NO'Donnell JGreenberg SMRosand J: Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology 63:105910642004

  • 7

    Goldstein JNThomas SHFrontiero VJoseph AEngel CSnider R: Timing of fresh frozen plasma administration and rapid correction of coagulopathy in warfarin-related intracerebral hemorrhage. Stroke 37:1511552006

  • 8

    Hemphill JC 3rdBonovich DCBesmertis LManley GTJohnston SC: The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32:8918972001

  • 9

    Kennedy JHill MDRyckborst KJEliasziw MDemchuck AMBucham AM: Fast assessment of stroke and transient ischemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial. Lancet Neurol 6:9619692007

  • 10

    Kessler CM: Urgent reversal of warfarin with prothrombin complex concentrate: where are the evidence-based data?. J Thromb Haemost 4:9639662006

  • 11

    Koc RKAkdemir HOktem ISMeral MMenku A: Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev 20:2392441997

  • 12

    Konig SASchick UDohnert JGoldammer AVitzthum HE: Coagulopathy and outcome in patients with chronic subdural haematoma. Acta Neurol Scand 107:1101162003

  • 13

    Lankiewicz MWHays JFriedman KDTinkoff GBlatt PM: Urgent reversal of warfarin with prothrombin complex concentrate. J Thromb Haemost 4:9679702006

  • 14

    Mayer SA: Complications in patients with intracerebral hemorrhage treated with recombinant factor VIIa. Neurology 69:3193202007

  • 15

    Rosand JEckman MHKnudsen KASinger DEGreenberg SM: The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med 164:8808842004

  • 16

    Seelig JMBecker DPMiller JDGreenberg RPWard JDChoi SC: Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. N Engl J Med 304:151115181981

  • 17

    Servadei FNasi MTGiuliani GCremonini AMCenni PZappi D: CT prognostic factors in acute subdural haematomas: the value of the ‘worst’ CT scan. Br J Neurosurg 14:1101162000

  • 18

    Sorensen BJohansen PNielsen GLSorensen JCIngerslev J: Reversal of the International Normalized Ratio with recombinant activated factor VII in central nervous system bleeding during warfarin thromboprophylaxis: clinical and biochemical aspects. Blood Coagul Fibrinolysis 14:4694772003

  • 19

    Steiner TRosand JDiringer M: Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions. Stroke 37:2562622006

  • 20

    Suarez JIZaidat OOSuri MFFeen ESLynch GHickman J: Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med 32:231123172004

  • 21

    Tuhrim SDambrosia JMPrice TRMohr JPWolf PAHier DB: Intracerebral hemorrhage: external validation and extension of a model for prediction of 30-day survival. Ann Neurol 29:6586631991

  • 22

    van Swieten JCKoudstaal PJVisser MCSchouten HJvan Gijn J: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 19:6046071988

  • 23

    Wilberger JE JrHarris MDiamond DL: Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 74:2122181991


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