Journal of The Association of Physicians of India ■ Vol.
63 ■ August 2015 79
Spontaneous Resolution of Chronic Subdural Haematoma in a
Patient Receiving Anticoagulant Therapy
Shailendra Ratre1, Yadram Yadav 2, Sushma Choudhary3, Vijay Parihar1
Abstract
Significant chronic subdural hematoma (CSDH) is usually a surgical emergency.
Spontaneous resolution of CSDH has rarely been reported in the literature. We
are reporting a case of spontaneous resolution of CSDH in a patient receiving
anticoagulant therapy who had undergone mitral valve replacement surgery.
Introduction
C hronic subdural hematoma (CSDH)
is a common type of intracranial
hemorrhage and is predominantly
seen in the elderly. The most common
cause of this lesion is head injury,
but several predisposing factors
such as coagulopathy, alcoholism,
cerebrospinal fluid shunt procedures,
vascular malformations, seizure
disorders, and metastatic tumors must
be ruled out. Response to surgery
h a s b e e n ve r y s a t i s f a c t o r y a n d i s
generally considered the treatment
of choice. 1 Spontaneous resolution
of CSDH has rarely been reported
in the literature, and its mechanism
has not been fully investigated. We
are reporting an extremely rare case
of spontaneous resolution of CSDH
in a patient receiving anticoagulant
therapy, presented with symptoms
of raised intracranial pressure and
midline shift on imaging.
Case Report
A 40-year-old woman presented
with 2 months history of holocranial
headache, which had increased in
severity over the past few days, with
vomiting. She was a known case of
rheumatic heart disease with mitral
valve stenosis and underwent mitral
valve replacement 1 year back. She was
on acenocoumarin as anticoagulant.
On examination, she was conscious,
oriented with no neurological
deficit. Fundus examination showed
papilledema. CT head revealed a large
left fronto-parietal CSDH with brain
oedema, mass effect and midline shift
(Figure 1). Her international normalized
ratio (INR) was of 10. Anticoagulant
considerable difficulty in diagnosis by
CT scan. MRI could help in making the
diagnosis of such lesion. 6
Surgery is generally considered
the treatment of choice for CSDH, but
conservative management of CSDH in
some patients on anticoagulant therapy
have been reported in the literature. 7,8
Literature concerning spontaneous
drug (acenocoumarin) was stopped resolution of CSDH (due to any cause)
and vitamin K was supplemented. with medical treatment consists of
As patient was neurologically stable,
she was kept under close observation
on decongestants and steroids
small case series and very few clinical
observations. 9 Reports focusing on
spontaneous resolution of CSDH
(Dexamethasone 4 mg four times in patients receiving anticoagulant
a day) and surgery was postponed th era p y i s very s p a rse . 7,8 T o t a l 1 5
until normalization of coagulation reports including 286 patients are
profile which was 10 days. Patient published on non-surgical treatment
improved symptomatically in terms of of all types of CSDH till now. 9
headache and her vomiting subsided Va r i o u s t h e o r i e s h a v e b e e n
c o m p l e t e l y . R e p e a t C T h e a d wa s suggested to explain the mechanisms
planned before surgery which revealed of formation and resolution of CSDHs.
almost complete resolution of CSDH Corticosteroids inhibited the formation
and brain oedema with total correction of protein-permeable membrane,
of midline shift (Figure 2). Patient was d e c r e a s i n g t h e s i z e o f C S D H . 10
discharged and at 2 months follow up Maturation of the neomembrane and
patient is doing well. stabilization of the neovasculature
might eventually result in spontaneous
Discussion
resolution. 11 In our case steroids may
have played role in resolution. CSDHs
Chronic subdural hematoma
with idiopathic thrombocytopenic
(CSDH) is one of the most common
purpura may resolve spontaneously
neurosurgical conditions. The trauma
or with medical treatment. Surgery
and antithrombotic therapy are the
might be deferred except in emergency
most frequent risk factors.2 The
incidence of CSDHs in patients on conditions or in patients with
warfarin is reported as between 21% neurological deficit. Close neurological
and 36%. Majority of spontaneous and radiological observation along
CSDHs (75%) patients are found to with the medical treatment could be
b e o n a n t i c o a g u l a n t s . 3 , 4 B e r wa e r t s appropriate in patients with normal
et al found hypertension, an INR neurological findings. 12 Early surgery
on admission of more than 4.5, and without correction of coagulopathy
the duration of anticoagulation, as is a risk factor in the recurrence. 13
significant risk factors for intracranial Nontraumatic SDHs or hygromas
hemorrhages in patients receiving in infants can often experience
oral anticoagulant therapy. 5 CT with significant resolutions within several
contrast and magnetic resonance months without surgical treatment. 16
imaging are diagnostic of CSDH. Spontaneous resolution of post-
Bilateral isodense CSDH may cause traumatic CSDH in patients without
1
Assistant Professor, 2Assosciate Professor, Dept. of Neurosurgery, 3Senior Resident, Department of Medicine, NSCB Medical
College, Jabalpur, Madhya Pradesh
Received: 30.05.2014; Revised: 12.07.2014; Accepted: 15.07.2014
 80 Journal of The Association of Physicians of India ■ Vol. 63 ■ August 2015

Fig. 1: CT scan of patient showing left fronto-parietal chronic Fig. 2: Repeat CT scan showing almost complete resolution of
subdural haematoma with midline shift haematoma with a small residual part

any associated coagulopathy, though
rare, can occur. Careful conservative
treatment can be considered if the
patient’s neurological and physical
conditions allow. 15
Surgery can be delayed in such
patients to correct the deranged
coagulation profile if neurological
2. Asghar M, Adhiyaman V, Greenway MW, et al. Chronic
subdural hematoma in the elderly-A North Wales
experience. JR Soc Med 2002; 95:290-92.
3. Gonogunta V, Buxton N. Warfarin and chronic subdural
hematomas. Br J Neurosurg 2001; 15:514-17.
4. Hylek E, Singer D. Risk factors for intracranial haemorrhage
in outpatients taking warfarin. Ann Intern Med 1994;
120:897-902.
5. Berwaerts J, Webster J. Analysis of risk factors involved in
oral-anticoagulant-related intracranial haemorrhages. QJ
10. Glover D, Labadie EL. Physiopathogenesis of subdural
hematomas. Part 2: Inhibition of growth of experimental
hematomas with dexamethasone. J Neurosurg 1976;
45:393-7.
11. Lee KS. Natural history of chronic subdural haematoma.
Brain Inj 2004; 18:351-8.
12. Seçkin H, Kazanci A, Yigitkanli K, Simsek S, Kars HZ.
Chronic subdural hematoma in patients with idiopathic
thrombocytopenic purpura: A case report and review of
the literature. Surg Neurol 2006; 66:411-4.

condition of patient permits under
close neurological and radiological
observation. The need of repeat CT head
prior to planned surgery is stressed
once coagulation profile normalises.
F i n a l l y f u r t h e r i n ve s t i g a t i o n s a r e
needed to understand mechanisms of
resolution of CSDH.
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