Effect of Anticoagulation Reversal on Hemostasis in Traumatic Parafalcine Subdural Hematoma

Introduction: Recent literature has questioned whether patients with traumatic intracranial hemorrhage (ICH) on an oral anticoagulant (OAC) require anticoagulation (AC) reversal in populations that are predominantly neurologically intact. A parafalcine subdural hematoma (SDH) is associated with a low incidence of hematoma progression and favorable neurologic outcomes relative to other select ICH locations. This study aims to assess the impact of AC reversal vs no treatment on hemostasis in patients with a parafalcine SDH.


Methods: This IRB-exempt retrospective cohort study at two Trauma Centers included patients presenting between 03/01/2016 to 10/31/2024 with a parafalcine SDH while receiving an OAC. Patients were excluded if they had an additional ICH location. Cohorts were based on receipt of treatment for AC reversal. The primary outcome was hemostasis on first repeat computed tomography of the head, defined as absence of any bleeding progression, tested for superiority with the Fisher’s exact test. Secondary endpoints include neurosurgical intervention, hematoma expansion > 35%, rescue treatment for AC reversal, in-hospital mortality or hospice, and thrombotic events within 7 days.


Results: 53 patients (median (IQR) age, 78.0 (68.0-87.0); mean (SD) Glasgow Coma Scale (GCS), 14.9 (0.3); apixaban, 26 (49.1%); mean (SD) SDH thickness, 4.1 (2.7) mm) were included, 18 (control) vs 35 (reversal). Baseline characteristics were similar except the reversal cohort had a higher median (IQR) Injury Severity Score 10.0 (9.0-10.0) vs 14.0 (10.0-20.0) (p = 0.0008), higher mean (SD) head Abbreviated Injury Scale 3.0 (0.0) vs 3.4 (0.6) (p = 0.0002), and higher proportion of ICU admissions 7 (38.9%) vs 24 (68.6%) (p = 0.0378). The primary outcome occurred in 16 (88.9%) (control) vs 32 (91.4%) (reversal) patients (p = 1.0000). No patients required neurosurgical intervention. Hematoma expansion > 35% (1 (5.6%) vs 0 (p = 0.3462)) and the need for rescue treatment (0 vs 1 (2.9%) (p = 1.00)) was infrequent. 1 (2.9%) patient in the reversal group was discharged to hospice (p = 1.00). No thrombotic events occurred.


Conclusions: Receipt of AC reversal in the setting of a parafalcine SDH did not appear to impact hemostasis in a population with a baseline GCS of 14-15 and with a baseline hematoma thickness predominantly < 1.0 cm.