Case Scenario:
A 58-year-old man presents to the emergency department with a sudden onset of severe headache for the past 1 hour. He describes it as “the worst headache of my life.” The pain started abruptly while he was watching TV and is associated with nausea, vomiting, and photophobia.
He underwent mitral valve replacement surgery 4 weeks ago and has since been on warfarin. His family reports that he has not had his INR checked for the past 10 days. There is no history of head trauma, seizures, or loss of consciousness.
Examination:
BP 170/100 mmHg, HR 84 bpm
Conscious but drowsy
Neck stiffness present
No focal neurological deficit
Investigations:
INR: 5.3 (elevated)
CT Brain: Diffuse subarachnoid hemorrhage around the circle of Willis
CBC, electrolytes: Normal
Diagnosis:
Warfarin-associated subarachnoid hemorrhage (post–mitral valve replacement)
Management:
Stop warfarin immediately
Reverse anticoagulation: IV Vitamin K + PCC/FFP
Control BP: Keep SBP <140 mmHg
Neurosurgical and cardiology consults
Monitor neurological status and repeat CT if it worsens
Avoid NSAIDs and antiplatelets.