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Spontaneous Subdural Hematoma and Antiplatelet Therapy i n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 3 0 – s 3 5 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/ihj Case Reports Spontaneous subdural hematoma and antiplatelet therapy: Does efficacy of Ticagrelor come with added risk? a, Pattanagere Manjunatha Suryanarayana Sharma *, b c Aniruddha Tekkatte Jagannatha , Mahendra Javali , d e a Anupama Venkatasubba Hegde , Rohan Mahale , Madhusudhan , f Rangasetty Srinivasa a Senior Resident, Department of Neurology, M.S. Ramaiah Medical College, Bangalore 560054, India b Associate Professor of Neurosurgery, M.S. Ramaiah Medical College, Bangalore 560054, India c Associate Professor of Neurology, M.S. Ramaiah Medical College, Bangalore 560054, India d Assistant Professor of Cardiology, M.S. Ramaiah Medical College, Bangalore 560054, India e Assistant Professor of Neurology, M.S. Ramaiah Medical College, Bangalore 560054, India f Senior Professor & Head, Department of Neurology, M.S. Ramaiah Medical College, Bangalore 560054, India a r t i c l e i n f o a b s t r a c t Article history: Antiplatelet therapy has established clinical benefit on cardiovascular outcome and has Received 2 March 2015 reduced the rates of re-infarction/in stent thrombosis following percutaneous coronary Accepted 16 June 2015 intervention in acute coronary syndromes. Major bleeding episodes can occur with anti- Available online 10 September 2015 platelet therapy and intracranial hemorrhage (ICH) is one of the most feared complications resulting in significant morbidity and mortality. Identification of high risk groups and Keywords: judicious use of antiplatelet therapy reduces the bleeding risk. Ticagrelor is a newer P2Y12 receptor antagonist with established clinical benefit. However, risks of having an Antiplatelet therapy Ticagrelor ICH with these newer molecules cannot be ignored. Here, we report a case of spontaneous acute subdural hematoma developing in a patient on antiplatelet therapy with aspirin and Intracranial hemorrhage ticagrelor. Early recognition, discontinuation of the medication and appropriate manage- Subdural hematoma ment resulted in resolution of hematoma and good clinical outcome. Authors have reviewed Acute coronary syndrome the antithrombotic drugs and their tendencies in causing intracranial bleeds from a neu- rophysicians perspective. # 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved. * Corresponding author. E-mail address: [email protected] (P.M. Suryanarayana Sharma). http://dx.doi.org/10.1016/j.ihj.2015.06.024 0019-4832/# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved. i n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 3 0 – s 3 5 S31 with history of retrosternal burning pain of 4 h duration. He 1. Introduction was a diabetic, and was on oral hypoglycemic agents for 16 years. He denied smoking and was normotensive. In the recent times, early intervention strategies and advances He was hemodynamically stable with a heart rate of 92 in antiplatelet therapy have reduced the risk of recurrent beats per minute and blood pressure of 150/80 mmHg. coronary events and mortality in patients with acute coronary Cardiovascular examination was unremarkable. His electro- syndromes (ACS). Antiplatelet therapy has been proven of cardiogram showed sinus rhythm without any acute ST-T major clinical benefit in cardiovascular clinical trials and is wave changes and features of left ventricular hypertrophy. routinely prescribed in secondary prevention. However, major Serial cardiac biomarkers were negative, (Troponin T – bleeding is a life threatening complication of triple antiplatelet 0.019 ng/ml (0 h), <0.010 ng/ml (6 h) respectively). Transtho- 1 therapy, and it can increase the risk of in-hospital death by 60%. racic echocardiography was normal. He was diagnosed to have Also, major bleeding episodes can adversely affect long-term unstable angina and was started on glycoprotein IIb/IIIa prognosis by increasing the 1-year mortality and re-infarction inhibitors, antiplatelets, statins, and insulin. Coronary angio- 2 rates by five-fold. Some patient subsets are at increased risk of gram done subsequently revealed single vessel coronary having a major bleed. Ticagrelor is a newer reversible P2Y12 artery occlusive disease. Left main coronary artery was receptor antagonist, reported to be more effective than existing normal. Left anterior descending artery was a type III vessel 3 antiplatelet therapies with a similar safety profile. However, with 40% occlusive lesion in mid D1 segment. Left circumflex long-term safety data are still awaited. Here, we report a 58- artery (LCX) was non-dominant with 80% lesion after major year-old male who developed spontaneous acute subdural OM1. Right coronary artery was dominant without any hematoma (SDH) on antiplatelet therapy with Aspirin and disease. Successful Percutaneous Transluminal Coronary ticagrelor following percutaneous coronary intervention (PCI) Angioplasty (PTCA) and stenting were done to mid LCX with ® for a cardiac event and placing a drug eluting stent. Supraflex (Cobalt Chromium Sirolimus eluting Stent system) stent of a caliber 3.0 mm  16 mm. Patient had uneventful recovery following the procedure, and he was discharged on 2. Case report day 5 with a multitude of drugs including Aspirin, Ticagrelor, Statins, Angiotensin Converting Enzyme inhibitors, Ranola- This 58-year-old male without any previous history of zine, Nikorandil, Insulin, and Proton pump inhibitors. He was ischemic heart disease was admitted to the cardiology services advised a periodic follow-up. Fig. 1 – CT head plain axial view. (A–C) A right temporoparietal acute subdural hematoma, mild mass effect with effacement of sulci and (D) intact calvaria on bone windows. S32 i n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 3 0 – s 3 5 Six weeks on antiplatelet therapy, the patient presented receive aspirin and was added on clopidogrel, as cardiologists with progressively increasing right hemicranial headache of 10 felt that stopping all of the antiplatelet drugs could have been days duration involving the right temporoparietal and frontal too risky. He was started on analgesics, followed by short region. It was of throbbing type, present throughout the day course of steroids and head end elevation. Headache reduced and was associated with nausea and vomiting. He had no on day 4 of therapy, and he was discharged. Repeat CT brain on diplopia, blurring of vision, seizures, loss of consciousness, or day 7 revealed a resolving hematoma as shown in Fig. 2. He limb weakness. He did not complain of hematemesis, remained asymptomatic at 90-day follow-up. hematuria, melena or bleeding per rectum. He denied any history of head trauma. He was evaluated by the neurology 3. Discussion team and admitted for further management. Clinical examination revealed a conscious, irritable patient with stable hemodynamic parameters. There was no papil- Intracranial hemorrhage (ICH) is the most feared bleeding loedema or cranial nerve involvement. He did not have any complication known to occur in a patient on antiplatelet lateralizing neurodeficits. Routine blood investigations includ- therapy following PCI. Here, we describe a case of spontaneous ing hemogram, coagulation parameters, liver function, and acute SDH in a patient with ischemic heart disease on renal function tests were normal. Cardiac evaluation including antiplatelet therapy with Aspirin and Ticagrelor following electrocardiogram, transthoracic echocardiography, and car- PCI. He recovered with no residual neurological deficits. diac biomarker levels were normal. Noncontrast computed Timely withdrawal of ticagrelor resulted in resolution of tomography (CT scan) on head revealed a right temporopar- hematoma and improvement in the patient symptoms. Early ietal acute SDH (Fig. 1). There was no evidence of fracture or recognition of this complication with appropriate manage- external contusion. Rest of the brain parenchyma was normal. ment resulted in a good outcome in this patient. This patient had a spontaneous acute right temporoparietal Bleeding complications after antiplatelet therapy have SDH. been long recognized and well-studied in large randomized A neurosurgical consultation was sought, and the patient trials. They constitute a key safety end point in all clinical trials 4 was planned for conservative therapy and observation. He was assessing newer antiplatelet drugs in ACS. In clinical trials, monitored for progression of intracranial hematoma. As he major bleeding is reported in 1–10% of all patients on was on antiplatelet therapy and developed an intracranial antiplatelet therapy, and it is a cause of significant morbidity 5 bleed, a decision was made to stop ticagrelor. He continued to and mortality. The factors predisposing to increased risk of Fig. 2 – Repeated CT after a week. CT head plain axial view. (A–C) Resolving subdural hematoma and (D) intact calvaria on bone windows. i n d i a n h e a r t j o u r n a l 6 7 ( 2 0 1 5 ) s 3 0 – s 3 5 S33 having a major bleed are elderly patients, female sex, low body aspirin with pooled odds ratio of 1.6, suggesting that Aspirin was 11 weight, impaired renal function, base line anemia, and a safe antiplatelet therapy. Wong et al. observed that 6 previous history of intracerebral haemorrhage. It is interest- incidence of lobar hematoma was more (32.8%) in aspirin users ing to note that ICH is uniformly classified as fatal/life compared to control groups (10.3%), and this was statistically 7 8 9 threatening bleeding as per PLATO, TIMI, and GUSTO trial significant. 12 definitions, though definition of a major bleed varies from Bakheet et al. have reported on a meta-analysis of 11 trial-to-trial. Occurrence of ICH in turn is associated with randomized trials analyzing the incidence of SDH in patients on increased risk of mortality and residual neurological deficit.
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