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      Spontaneous acute subdural hematoma due to fondaparinux: Report of two cases

      case-report

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          Abstract

          Background:

          Spontaneous acute subdural hematomas (SDHs) are rare. Risk factors for development of these hematomas include conditions such as hypertension, vascular abnormalities such as aneurysm or arteriovenous malformation, or consumption of anticoagulants.

          Case Description:

          Here, the authors report two patients who suffered from spontaneous acute SDH while taking fondaparinux for venous thromboembolism prophylaxis. One patient suffered from a remote episode of traumatic brain injury and underwent a decompressive craniectomy 3 weeks prior to presentation, whereas the other patient had been self-medicating with aspirin.

          Conclusion:

          To our knowledge, these two patients illustrate the first cases of spontaneous acute SDH formation most likely attributed to consumption of fondaparinux.

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          Most cited references34

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          Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery.

          , B Eriksson, Manuel Bauer … (2001)
          Surgery for hip fracture carries a high risk of venous thromboembolism, despite the use of current thromboprophylactic treatments. Fondaparinux, a synthetic pentasaccharide, is a new antithrombotic agent that may reduce this risk. In a double-blind study, were randomly assigned 1711 consecutive patients undergoing surgery for fracture of the upper third of the femur to receive subcutaneous doses of either 2.5 mg of fondaparinux once daily, initiated postoperatively, or 40 mg of enoxaparin once daily, initiated preoperatively, for at least five days. The primary efficacy outcome was venous thromboembolism up to postoperative day 11. Venous thromboembolism was defined as deep-vein thrombosis detected by mandatory bilateral venography, documented symptomatic deep-vein thrombosis, or documented symptomatic pulmonary embolism. The main safety outcomes were major bleeding and mortality from all causes. The duration of follow-up was six weeks. The incidence of venous thromboembolism by day 11 was 8.3 percent (52 of 626 patients) in the fondaparinux group and 19.1 percent (119 of 624 patients) in the enoxaparin group (P<0.001). The reduction in risk with fondaparinux was 56.4 percent (95 percent confidence interval, 39.0 to 70.3 percent). There were no significant differences between the two groups in the incidence of death or clinically relevant bleeding. In patients undergoing surgery for hip fracture, fondaparinux was more effective than enoxaparin in preventing venous thromboembolism and equally safe.
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            Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery.

            A Turpie, Bengt I Eriksson, M Lassen … (2001)
            Despite thromboprophylaxis, major knee surgery carries a high risk of venous thromboembolism. Fondaparinux, the first of a new class of synthetic antithrombotic agents, may reduce this risk. In a double-blind study, we randomly assigned 1049 consecutive patients undergoing elective major knee surgery to receive subcutaneous doses of either 2.5 mg of fondaparinux once daily or 30 mg of enoxaparin twice daily, with both treatments initiated postoperatively. The primary efficacy outcome was venous thromboembolism up to postoperative day 11, defined as deep-vein thrombosis detected by mandatory bilateral venography, documented symptomatic deep-vein thrombosis, or documented symptomatic pulmonary embolism. The primary safety outcome was major bleeding. The primary efficacy outcome was assessed in 724 patients. The fondaparinux group had a significantly lower incidence of venous thromboembolism by day 11 (12.5 percent [45 of 361 patients]) than the enoxaparin group (27.8 percent [101 of 363 patients]; reduction in risk, 55.2 percent; 95 percent confidence interval, 36.2 to 70.2; P<0.001). Major bleeding (including overt bleeding with a bleeding index of 2 or more) occurred more frequently in the fondaparinux group (P=0.006), but there were no significant differences between the two groups in the incidence of bleeding leading to death or reoperation or occurring in a critical organ. In patients undergoing elective major knee surgery, postoperative treatment with 2.5 mg of fondaparinux once daily was significantly more effective in preventing deep-vein thrombosis than 30 mg of enoxaparin twice daily.
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              Prevention of venous thromboembolism in surgical patients.

              Giancarlo Agnelli (2004)
              Venous thromboembolism (VTE) is a common complication of surgical procedures. The risk for VTE in surgical patients is determined by the combination of individual predisposing factors and the specific type of surgery. Prophylaxis with mechanical and pharmacological methods has been shown to be effective and safe in most types of surgery and should be routinely implemented. For patients undergoing general, gynecologic, vascular, and major urologic surgery, low-dose unfractionated heparin or low-molecular-weight heparin (LMWH) are the options of choice. For low-risk urologic surgery, early postoperative mobilization of patients is the only intervention warranted. For higher-risk patients, including those undergoing elective hip or knee replacement and surgery for hip fracture, vitamin K antagonists, LMWH, or fondaparinux are recommended. For patients undergoing neurosurgery, graduated elastic stockings are effective and safe and may be combined with LMWH to further reduce the risk of VTE. The role of prophylaxis is less defined in patients undergoing elective spine surgery, as well as laparoscopic and arthroscopic surgery. A number of issues related to prophylaxis of VTE after surgery deserve further clarification, including the role of screening for asymptomatic deep vein thrombosis, the best timing for initiation of pharmacological prophylaxis, and the optimal duration of prophylaxis in high-risk patients.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Surg Neurol Int
                Journal ID (publisher-id): SNI
                Title: Surgical Neurology International
                Publisher: Medknow Publications Pvt Ltd (India )
                ISSN (Print): 2229-5097
                ISSN (Electronic): 2152-7806
                Publication date Collection: 2011
                Publication date (Electronic): 19 April 2011
                Volume: 2
                Electronic Location Identifier: 44
                Affiliations
                [1]St. Francis Hospital, Division of Neurological Surgery, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
                [1 ]Goodman Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, IN, USA
                Author notes
                [* ]Corresponding author
                Article
                Publisher ID: SNI-2-44
                DOI: 10.4103/2152-7806.79759
                PMC ID: 3108447
                PubMed ID: 21660271
                SO-VID: adc0fdbc-b08d-458b-9d95-38acf9d3636f
                Copyright © Copyright: © 2011 Fryburg K.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 17 March 2011
                Date accepted : 22 March 2011
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Keywords: fondaparinux,decompressive craniectomy,venous thromboembolism prophylaxis,acute subdural hematoma
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: fondaparinux, decompressive craniectomy, venous thromboembolism prophylaxis, acute subdural hematoma

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