Warfarin fall with thin subdural, young extradural, and refractory pressure — reversal, millimetres, and rescue

Viva

Q1: The 78-year-old on warfarin — admit, reverse, or reassure?

Admit and reverse. Warfarin predicts death (OR 2.27) where antiplatelets alone do not; elderly operative mortality runs 42% with falls dominant — a thin film with a normal exam still earns reversal, observation and a repeat scan.^[32][45] Reverse by INR with CT and examination guiding pace — protocolised rapid reversal may cut mortality by up to 38% at proposal-level evidence — and note DOACs injure less (immediate-bleed OR 0.58) without a mortality difference if he had been on one instead.^[34][33]

Q2: The 22-year-old extradural at 35 cm³ — operate tonight?

Yes — above 30 cm³ evacuates at any GCS, and drowsiness means the lucid interval is closing.^[14] Counsel from the Hong Kong series: 90% survival with 91% of survivors good-or-moderate, but GCS 3 with bilaterally fixed pupils is the unsurvivable exception — which he is not.^[15]

Q3: The refractory 30-year-old — rescue craniectomy or barbiturate coma?

He sits in the RESCUEicp doorway (above 25 sustained despite tiers) — rescue halves 6-month death (26.9 vs 48.9%) at vegetative and severe-disability cost, never offer DECRA-style early moderate-pressure surgery which worsened function (OR 1.84/2.21) without saving lives.^[2][1] Coma rescues 40% where theatre cannot reach; here theatre can.^[2]

Q4: Counsel the rescue family with numbers, not adjectives.

Per 100 operated at 24 months: 21 extra alive — 4 vegetative, 9 severely disabled, 8 moderately disabled, none extra fully recovered — with nearly a third of surgical survivors still gaining grades between 6 and 24 months.^[3]