Successful management of an acute subdural hematoma in a patient dependent on continuous treprostinil infusion therapy

Case report

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Treprostinil is a synthetic analog of prostacyclin, which is used for treatment of pulmonary arterial hypertension (PAH). Continuous subcutaneous administration of treprostinil has been proven in randomized controlled trials to improve quality of life, hemodynamics, and 5-year survival in patients with PAH. The efficacy of treprostinil has been attributed to its vasodilatory and antiplatelet effects. Unfortunately, the efficacy of treprostinil in the treatment of PAH is rapidly reversed upon cessation of the continuous infusion. Furthermore, cases of patients rapidly declining or succumbing to disease progression upon cessation of treprostinil have raised significant concern regarding discontinuation of this medication. To date, there are no reports of emergency craniotomies performed in the setting of continuous subcutaneous infusion of treprostinil. The authors report a case of a patient with PAH, treated with continuous administration of subcutaneous treprostinil as well as warfarin, who developed an acute subdural hematoma (SDH). Despite adequate INR (international normalized ratio) correction, the patient eventually underwent an emergency craniotomy for evacuation of the SDH while on continuous treprostinil administration. This case highlights the neurosurgical dilemma regarding the appropriate management of acute SDHs in patients receiving continuous treprostinil infusion.

Abbreviations used in this paper:INR = international normalized ratio; PAH = pulmonary arterial hypertension; SDH = subdural hematoma.

Article Information

Address correspondence to: Ron I. Riesenburger, M.D., Department of Neurosurgery, Tufts Medical Center, Proger 7, 800 Washington Street, Boston, Massachusetts 02110. email:

Please include this information when citing this paper: published online February 1, 2013; DOI: 10.3171/2013.1.JNS121512.

© AANS, except where prohibited by US copyright law.



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    Axial noncontrast head CT scans obtained throughout the patient's hospital stay. A: Admission scan showing an acute right SDH measuring 1.2 cm in greatest thickness. B: Scan prior to operative management demonstrating expansion of the SDH to 1.8 cm and significant increase in midline shift. C: Postoperative scan showing evacuation of the SDH and resolution of midline shift. D: Three-month follow-up scan revealing continued evolution of the residual SDH.


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