A 72-year-old man on warfarin for atrial fibrillation (INR 3.2) falls from standing height and strikes his head. Three hours later he becomes progressively drowsy with a fixed dilated left pupil and right-sided weakness; GCS drops from 14 to 8. Non-contrast CT head is shown. The structure marked **A** is a crescent-shaped hyperdense extra-axial collection over the left cerebral convexity measuring 18 mm thickness with 12 mm midline shift. Which of the following is the MOST APPROPRIATE immediate management step?
A. Initiate mannitol 1 g/kg IV and head-up positioning; defer surgical intervention pending repeat imaging in 6 hours
B. Administer fresh frozen plasma (FFP) 15 mL/kg and observe for 24 hours before considering surgical intervention
C. Perform bilateral burr hole drainage under local anesthesia to relieve the mass effect
D. Administer 4-factor prothrombin complex concentrate (PCC) and IV vitamin K 10 mg to reverse anticoagulation, followed by urgent craniotomy for evacuation
Explanation
Why option 1 is correct
The structure marked A is an acute subdural hematoma (SDH) — a crescent-shaped hyperdense extra-axial collection that crosses suture lines but is limited by the falx cerebri. The clinical presentation of progressive drowsiness, fixed dilated ipsilateral pupil (indicating uncal herniation from mass effect), and right-sided weakness with GCS deterioration in a warfarin-anticoagulated patient constitutes a neurosurgical emergency. According to Bailey & Love 28e, acute SDH with thickness >10 mm, midline shift >5 mm, or neurological deterioration requires urgent craniotomy for evacuation. Anticoagulation reversal is the FIRST step: 4-factor PCC (which contains factors II, VII, IX, X) plus IV vitamin K 10 mg is the gold standard for rapid warfarin reversal — it works within 30 minutes, whereas FFP is too slow and volume-heavy. This patient meets all criteria for emergency decompression.
Why each distractor is wrong
Option 2 (FFP): Fresh frozen plasma is no longer recommended for warfarin reversal in acute intracranial hemorrhage. FFP requires large volumes (15 mL/kg), is slow to act (4–6 hours), and risks volume overload in elderly patients. PCC is the standard of care. Observation for 24 hours is contraindicated — this patient is herniation and requires immediate surgery.
Option 3 (Burr hole drainage): Burr hole drainage is the definitive treatment for chronic SDH (>3 weeks, hypodense on CT), not acute SDH. Acute SDH requires craniotomy for complete evacuation and hemostasis. Burr holes are inadequate for thick acute collections and would not address the ongoing bleeding from torn bridging veins.
Option 4 (Mannitol + observation): While mannitol and head-up positioning are important temporizing measures for raised ICP, they are NOT definitive management for acute SDH with mass effect and herniation signs. Deferring surgery for 6 hours in a herniation patient is inappropriate and risks death. Medical measures alone cannot evacuate the hematoma.
High-YieldNEET PG
Acute SDH >10 mm or with midline shift >5 mm + neurological deterioration = urgent craniotomy + PCC + vitamin K (not FFP). Chronic SDH = burr hole drainage.
Bailey & Love 28e, Head Injury; Warfarin reversal guidelines, American College of Chest Physicians
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