Valvular heart diseases have a mixed presentation in healthcare settings all over the world. Rheumatic heart disease still forms the major cause of these valvular lesions. Mitral and aortic valvular diseases top the list of valvular pathology.¹ Thereby, a thorough understanding of the pathophysiology of valvular heart disease is essential in planning anesthesia and perioperative care of such patients. Judicious use of fluids, close monitoring of the changing hemodynamics, and avoiding major reduction of cardiac output and fluid shifts are mandatory to achieve a good clinical outcome. These patients are at risk of the thromboembolic episode for which they are on long-term anticoagulation.² So timely monitoring of the coagulation profile is needed. The risk of bleeding increases if international normalized ratio (INR) >4.5.³ We hereby present a case of subdural hematoma in a case of severe mitral stenosis with warfarin toxicity posted for burr hole surgery.