Timing of Anticoagulation Resumption in a Patient With Mechanical Heart Valves and Spontaneous Subdural Hematomas: A Case Report

Managing anticoagulation in patients with mechanical heart valves who develop a spontaneous intracranial hemorrhage is a challenging clinical scenario. Currently, there are no established guidelines on the optimal timing for the resumption of anticoagulation in this high-risk population. We report a case of a 61-year-old male with mechanical mitral and aortic valves on warfarin therapy for 9 years who presented with atraumatic subdural hematomas. The patient's anticoagulation was reversed, and he underwent middle meningeal artery embolization. Early resumption of anticoagulation resulted in worsening subdural hematomas requiring craniotomies. Holding anticoagulation for 14 days and reinitiating with warfarin alone, without a heparin bridge, prevented subsequent intracranial hemorrhage and preserved valve function. In patients with mechanical heart valves who develop spontaneous subdural hematomas, a strategy of holding anticoagulation for 14 days, followed by reinitiation with warfarin alone, without a heparin bridge, may be a viable approach to prevent recurrent intracranial hemorrhage.