Surgical management of warfarin-associated spontaneous bilateral subdural hematoma in a mechanical heart valve patient: a rare case report

Background and importance: Subdural hematomas (SDH) may occur spontaneously in patients with intracranial hypotension or in those taking anticoagulants such as warfarin. Bilateral cases are rare and often indicate warfarin-induced vascular fragility. Case presentation: A 68-year-old male with a mechanical aortic valve on chronic warfarin therapy presented with dizziness and nausea and was initially diagnosed with a small left parietal subarachnoid hemorrhage, with imaging showing no vascular anomaly; it remained stable, and he was discharged. Forty days later, he was readmitted with dizziness and confusion, and imaging revealed bilateral acute SDH. Warfarin was discontinued and low-molecular-weight heparin was initiated, but rapid hemorrhage progression necessitated bilateral burr-hole evacuation, followed by reoperation for a recurrent right parietal hematoma. Anticoagulation was carefully adjusted due to the competing risks of valve thrombosis and rebleeding. Postoperatively, he developed transient hemiparesis that resolved, and subsequent ventricular dilatation was managed with lumbar puncture. Clinical discussion: Warfarin, widely used for cardiovascular disease, increases the risk of bleeding complications, including subdural hematoma, especially in patients with mechanical heart valves. Patients and clinicians are confronted with both clinical and surgical challenges. Conclusion: Subdural hematoma remains a challenging condition to manage. Timely surgical intervention might be necessary and life-saving, even while on warfarin therapy. Once the hemorrhage is controlled, anticoagulation can be safely resumed.