Influence of Antiplatelet and Anticoagulant Drug Use on Outcomes after Chronic Subdural Hematoma Drainage

Abstract

We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58-1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76-1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.

Low-Dose Acetylsalicylic Acid in Chronic Subdural Hematomas: A Neurosurgeon's Sword of Damocles

“…There were no cases of early recurrence (<1 week); Kamenova et al and Poon et al reported 28 cases of late recurrence and 13 thromboembolic events after surgery, without any statistically significant difference between patients who underwent discontinuation or not ( 6 , 8 ).…”

“…Four hundred thirty-nine patients were collected in this group. Four hundred seven (92.7%) patients discontinued LDAA on admission while 32 patients (7.3%) at least 5 days before surgery due to minor symptom presentation ( 6 – 8 ).…”

“…There were no cases of early recurrence (<1 week); Kamenova et al and Poon et al reported 28 cases of late recurrence of chronic subdural hematoma and 13 thromboembolic events after surgery. In Kamenova et al, 10 cardiovascular events comprised four myocardial infarction, one occlusion of femoral artery, three pulmonary embolisms, and two cardiac arrhythmia/decompensation, while in Poon et al, the severity of the thromboembolic events was not analyzed ( 6 , 8 ).…”

“…On the other hand, Poon et al and Szczygielski et al underlined the lack of clear indication for the management of these drugs, concluding that patients on antithrombotic drugs were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage ( 4 , 8 ).…”

“…The clinical outcome was reported in only two papers (Scerrati et al; Poon et al), and preoperative assessment is available only in the Scerrati et al series, undermining any possible LDAA management/complication rate/clinical outcome comparison between the groups ( 7 , 8 ).…”