{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T16:08:26Z","timestamp":1776096506276,"version":"3.50.1"},"reference-count":28,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"5","license":[{"start":{"date-parts":[[2026,2,2]],"date-time":"2026-02-02T00:00:00Z","timestamp":1769990400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,2,2]]},"abstract":"\n BACKGROUND<\/jats:title>\n Chronic subdural hematoma (cSDH) is a frequent neurosurgical condition, yet its preoperative natural history, particularly in patients receiving antiplatelet therapy, remains poorly defined. Although delaying surgery to allow aspirin washout is a common practice, the evidence supporting fixed discontinuation intervals is limited. Bilateral cSDH is associated with a higher risk of rapid deterioration, highlighting the need to consider emergency evacuation even in clinically stable patients.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n A 71-year-old man with a history of ischemic stroke on aspirin presented with bilateral cSDH causing moderate mass effect but preserved consciousness with mild right-sided hemiparesis. Aspirin was withdrawn and surgery scheduled after a standard 5-day washout. On day 3 of interruption, he developed abrupt neurological deterioration. Emergency CT showed acute rebleeding within both hematomas and marked mass effect consistent with impending transtentorial herniation. Urgent bilateral burr hole evacuation achieved complete decompression. However, postoperative imaging revealed bilateral posterior cerebral artery (PCA) territory infarctions with thalamic involvement, consistent with herniation-related compromise of the basilar apex and proximal PCA segments. The patient never regained consciousness.<\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n This case highlights the hazards of delaying surgery for aspirin washout in bilateral cSDH. Individualized risk assessment and early evacuation may help prevent catastrophic herniation-related posterior circulation infarction.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25934<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25934","type":"journal-article","created":{"date-parts":[[2026,2,5]],"date-time":"2026-02-05T13:30:07Z","timestamp":1770298207000},"source":"Crossref","is-referenced-by-count":0,"title":["Delayed evacuation of bilateral chronic subdural hematoma with herniation-induced bilateral posterior cerebral artery infarction: illustrative case"],"prefix":"10.3171","volume":"11","author":[{"given":"Mehdi","family":"Mdarhri","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Oualid Mohammed","family":"Hmamouche","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4720-492X","authenticated-orcid":true,"given":"Marouane","family":"Hammoud","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Faycal","family":"Lakhdar","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammed","family":"Benzagmout","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Khalid","family":"Chakour","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mohammed","family":"Chaoui El Faiz","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Hassan II University Hospital, Fez, Morocco"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"key":"bib1","series-title":"World Neurosurg","first-page":"339","article-title":"Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome","volume":"141","author":"Feghali","year":"2020","unstructured":"Feghali JYang WHuang J.Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome. World Neurosurg. 2020;141:339-345."},{"issue":"8","key":"bib2","series-title":"Ann R Coll Surg Engl","first-page":"584","article-title":"No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma","volume":"97","author":"Phang","year":"2015","unstructured":"Phang ISivakumaran RPapadopoulos MC.No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma. Ann R Coll Surg Engl. 2015;97(8):584-588."},{"issue":"1","key":"bib3","series-title":"Neuroradiology","first-page":"27","article-title":"Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis","volume":"63","author":"Miah","year":"2021","unstructured":"Miah IPTank YRosendaal FRRadiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. Neuroradiology. 2021;63(1):27-40."},{"issue":"7","key":"bib4","series-title":"Int J Surg","first-page":"544","article-title":"Bilateral chronic subdural hematoma: what is the clinical significance?","volume":"11","author":"Huang","year":"2013","unstructured":"Huang YHYang KYLee TCLiao CC.Bilateral chronic subdural hematoma: what is the clinical significance? Int J Surg. 2013;11(7):544-548."},{"issue":"4","key":"bib5","series-title":"Neurol Med Chir (Tokyo)","first-page":"198","article-title":"Bilateral chronic subdural hematoma is associated with rapid progression and poor clinical outcome","volume":"56","author":"Agawa","year":"2016","unstructured":"Agawa YMineharu YTani SAdachi HImamura HSakai N.Bilateral chronic subdural hematoma is associated with rapid progression and poor clinical outcome. Neurol Med Chir (Tokyo). 2016;56(4):198-203."},{"issue":"1","key":"bib6","series-title":"Acta Neurochir (Wien)","first-page":"39","article-title":"Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis","volume":"165","author":"Rychen","year":"2023","unstructured":"Rychen JSaemann AFingerlin TRisks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis. Acta Neurochir (Wien). 2023;165(1):39-47."},{"issue":"4","key":"bib7","series-title":"Neurosurg Focus","first-page":"E6","article-title":"Perioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures","volume":"55","author":"Rychen","year":"2023","unstructured":"Rychen JWeiger VFHalbeisen FSPerioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures. Neurosurg Focus. 2023;55(4):E6."},{"issue":"6","key":"bib8","series-title":"JAMA Neurol","first-page":"551","article-title":"Aspirin continuation or discontinuation in surgically treated chronic subdural hematoma: a randomized clinical trial","volume":"82","author":"Kamenova","year":"2025","unstructured":"Kamenova MPacan LMueller CAspirin continuation or discontinuation in surgically treated chronic subdural hematoma: a randomized clinical trial. JAMA Neurol. 2025;82(6):551-559."},{"issue":"5","key":"bib9","series-title":"J Neurosurg","first-page":"1529","article-title":"Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study","volume":"132","author":"Hanalioglu","year":"2019","unstructured":"Hanalioglu SSahin BSahin OSEffect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study. J Neurosurg. 2019;132(5):1529-1538."},{"key":"bib10","article-title":"Posterior cerebral artery stroke","author":"Kuybu","unstructured":"Kuybu OTadi PDossani RH.Posterior cerebral artery stroke. In: StatPearls. StatPearls Publishing; 2025. Accessed November 18, 2025. http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532296\/"},{"issue":"6","key":"bib11","series-title":"RadioGraphics","first-page":"1598","article-title":"Types of cerebral herniation and their imaging features","volume":"39","author":"Riveros Gilardi","year":"2019","unstructured":"Riveros Gilardi BMu\u00f1oz L\u00f3pez JIHern\u00e1ndez Villegas ACTypes of cerebral herniation and their imaging features. 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Cambridge University Press; 2012:405-418."},{"key":"bib1","series-title":"World Neurosurg","first-page":"339","article-title":"Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome","volume":"141","author":"Feghali","year":"2020","unstructured":"Feghali JYang WHuang J.Updates in chronic subdural hematoma: epidemiology, etiology, pathogenesis, treatment, and outcome. World Neurosurg. 2020;141:339-345."},{"issue":"8","key":"bib2","series-title":"Ann R Coll Surg Engl","first-page":"584","article-title":"No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma","volume":"97","author":"Phang","year":"2015","unstructured":"Phang ISivakumaran RPapadopoulos MC.No association between seniority of surgeon and postoperative recurrence of chronic subdural haematoma. Ann R Coll Surg Engl. 2015;97(8):584-588."},{"issue":"1","key":"bib3","series-title":"Neuroradiology","first-page":"27","article-title":"Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis","volume":"63","author":"Miah","year":"2021","unstructured":"Miah IPTank YRosendaal FRRadiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis. Neuroradiology. 2021;63(1):27-40."},{"issue":"7","key":"bib4","series-title":"Int J Surg","first-page":"544","article-title":"Bilateral chronic subdural hematoma: what is the clinical significance?","volume":"11","author":"Huang","year":"2013","unstructured":"Huang YHYang KYLee TCLiao CC.Bilateral chronic subdural hematoma: what is the clinical significance? Int J Surg. 2013;11(7):544-548."},{"issue":"4","key":"bib5","series-title":"Neurol Med Chir (Tokyo)","first-page":"198","article-title":"Bilateral chronic subdural hematoma is associated with rapid progression and poor clinical outcome","volume":"56","author":"Agawa","year":"2016","unstructured":"Agawa YMineharu YTani SAdachi HImamura HSakai N.Bilateral chronic subdural hematoma is associated with rapid progression and poor clinical outcome. Neurol Med Chir (Tokyo). 2016;56(4):198-203."},{"issue":"1","key":"bib6","series-title":"Acta Neurochir (Wien)","first-page":"39","article-title":"Risks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis","volume":"165","author":"Rychen","year":"2023","unstructured":"Rychen JSaemann AFingerlin TRisks and benefits of continuation and discontinuation of aspirin in elective craniotomies: a systematic review and pooled-analysis. Acta Neurochir (Wien). 2023;165(1):39-47."},{"issue":"4","key":"bib7","series-title":"Neurosurg Focus","first-page":"E6","article-title":"Perioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures","volume":"55","author":"Rychen","year":"2023","unstructured":"Rychen JWeiger VFHalbeisen FSPerioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures. Neurosurg Focus. 2023;55(4):E6."},{"issue":"6","key":"bib8","series-title":"JAMA Neurol","first-page":"551","article-title":"Aspirin continuation or discontinuation in surgically treated chronic subdural hematoma: a randomized clinical trial","volume":"82","author":"Kamenova","year":"2025","unstructured":"Kamenova MPacan LMueller CAspirin continuation or discontinuation in surgically treated chronic subdural hematoma: a randomized clinical trial. JAMA Neurol. 2025;82(6):551-559."},{"issue":"5","key":"bib9","series-title":"J Neurosurg","first-page":"1529","article-title":"Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study","volume":"132","author":"Hanalioglu","year":"2019","unstructured":"Hanalioglu SSahin BSahin OSEffect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study. J Neurosurg. 2019;132(5):1529-1538."},{"key":"bib10","article-title":"Posterior cerebral artery stroke","author":"Kuybu","unstructured":"Kuybu OTadi PDossani RH.Posterior cerebral artery stroke. In: StatPearls. StatPearls Publishing; 2025. Accessed November 18, 2025. http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532296\/"},{"issue":"6","key":"bib11","series-title":"RadioGraphics","first-page":"1598","article-title":"Types of cerebral herniation and their imaging features","volume":"39","author":"Riveros Gilardi","year":"2019","unstructured":"Riveros Gilardi BMu\u00f1oz L\u00f3pez JIHern\u00e1ndez Villegas ACTypes of cerebral herniation and their imaging features. RadioGraphics. 2019;39(6):1598-1610."},{"issue":"2","key":"bib12","series-title":"Korean J Neurotrauma","first-page":"341","article-title":"Fatal brain herniation in bilateral chronic subdural hematoma","volume":"18","author":"Ahn","year":"2022","unstructured":"Ahn YHKim JKim SW.Fatal brain herniation in bilateral chronic subdural hematoma. Korean J Neurotrauma. 2022;18(2):341-345."},{"key":"bib13","article-title":"Neuroanatomy, posterior cerebral arteries","author":"Javed","unstructured":"Javed KReddy VDas JM.Neuroanatomy, posterior cerebral arteries. In: StatPearls. StatPearls Publishing; 2025. Accessed November 18, 2025. http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK538474\/"},{"key":"bib14","series-title":"Stroke Syndromes","first-page":"405","article-title":"Posterior cerebral artery","author":"Chaves","year":"2012","unstructured":"Chaves CCaplan LR.Posterior cerebral artery. In: Caplan LR, van Gijn J, eds. Stroke Syndromes. 3rd ed. Cambridge University Press; 2012:405-418."}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/11\/5\/article-CASE25934.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/11\/5\/article-CASE25934.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/11\/5\/article-CASE25934.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T15:27:32Z","timestamp":1776094052000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/11\/5\/article-CASE25934.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,2]]},"references-count":28,"journal-issue":{"issue":"5"},"URL":"https:\/\/doi.org\/10.3171\/case25934","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,2]]}}}