A 65-year-old previously fit and well lady presented after collapsing with a sudden onset severe headache and nausea. She then developed a dense left hemiparesis and her GCS dropped to 6 (E1 V1 M4). Upon arrival at the emergency department she was intubated, and a computed tomography of the brain (CTB) revealed a 17 mm deep right acute-on-chronic SDH with 12 mm of midline shift. She had no history of trauma, did not take any regular medication (nor any sporadic doses of aspirin or nonsteroidal anti-inflammatory drugs in the months prior to admission), consume excess alcohol, or have any other cause for coagulopathy. She underwent a CT angiogram which did not show a vascular abnormality.
The patient underwent emergency craniotomy and evacuation of the SDH. Excellent hemostasis was noted during this operation. Postoperatively, she was admitted to neurointensive care where she remained intubated. After 4 hours, her GCS motor score dropped from 5 to 1 with equal and reactive pupils so she underwent a further CT scan. This showed a reduction in the size of subdural clot with persisting midline shift which was managed conservatively; 6 hours later her GCS had normalized and she was subsequently successfully extubated. However, in the next 2 to 3 hours, she became very drowsy and was no longer moving her left arm. A further CTB showed re-hemorrhage and she was taken back to theatre for repeat craniotomy and evacuation of SDH. This time her scalp was found to be "very oozy" with both subdural and extradural hematoma. Intraoperatively, a thromboelastogram (TEG) was performed, and the results (R 2.8, angle 34.4, and MA 19.6) were consistent with impaired platelet functioning. Based on these results, she was given 1 g tranexamic acid, 1 pool of platelets, and 2 units of cryoprecipitate. Her INR, APTR, and fibrinogen remained in the normal range throughout admission.
Eight hours post procedure she was awake and obeying commands. Postoperatively, she received a further 1 g tranexamic acid, 2 units of FFP, and 10 mg vitamin K to cover subgaleal and subdural drain removals.
Further questioning into her history revealed that she had been taking Red Clover for the preceding 8-10 years (364 mg per day of standardized Red Clover extract containing 40 mg isoflavones, as recommended by the manufacturer) as an over-the-counter herbal preparation for relief of menopausal symptoms. Red Clover was deemed to be a causative factor in her SDH and subsequent re-bleeding based on the abnormal TEG report showing impaired platelet functioning and absence of trauma or any other cause for coagulopathy.
A final CTB showed an improved SDH and reduced mass effect. Clinically, she was GCS 15 with a very mild right hemiparesis. She was transferred to her local neurosurgical unit for rehabilitation on postoperative day 3. At 6-month follow-up, she had returned to baseline functioning with no residual neurology.