Neurocritical Care

, Volume 30, Issue 2, pp 322–333 | Cite as

Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants

  • Christopher BeynonEmail author
  • Steffen Brenner
  • Alexander Younsi
  • Timolaos Rizos
  • Jan-Oliver Neumann
  • Johannes Pfaff
  • Andreas W. Unterberg
Original Article



Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited.


We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30 months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included.


A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment.


These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.


Intracranial hemorrhages Trauma Subdural hematoma Subdural hemorrhage Oral anticoagulants 



We thank Nick Bornschein (Statworx, Frankfurt, Germany) for assistance with statistical analyses.

Author’s Contribution

CB, SB, and AWU designed the study. CB, SB, and AY collected the data. CB, J-ON, and AWU analyzed the data and wrote the first draft of the manuscript. TR and JP analyzed the data and were major contributors in writing the manuscript. All authors read and approved the final manuscript.

Source of Support

There were no sources of funding received for this study.

Compliance with Ethical Standards

Conflict of interest

Christopher Beynon has received personal fees outside the submitted work from Bayer Healthcare, Boehringer Ingelheim, CSL Behring, and Tem International. Timolaos Rizos has received personal fees outside the submitted work from Bayer Healthcare, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, and Daiichi Sankyo. For the remaining authors, no competing financial interests exist.

Ethical Approval

The study has been approved by the institutional review board. For this type of retrospective study, formal consent is not required.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryHeidelberg University HospitalHeidelbergGermany
  2. 2.Department of NeurologyHeidelberg University HospitalHeidelbergGermany
  3. 3.Department of NeurologyAlfried Krupp Krankenhaus EssenEssenGermany
  4. 4.Department of NeuroradiologyHeidelberg University HospitalHeidelbergGermany

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