Predicting Chronic Subdural Hematoma Recurrence and Stroke Outcomes While Withholding Antiplatelet and Anticoagulant Agents

Abstract

The aging of the western population and the increased use of oral anticoagulation (OAC) and antiplatelet drugs (APD) will result in a clinical dilemma on how to balance the recurrence risk of chronic subdural hematoma (cSDH) with the risk of withholding blood thinners. Objective: To identify features that predicts recurrence, thromboembolism (TEE), hospital stay and mortality. To identify the optimal window for resuming APD or OAC. Methods: We performed a retrospective multivariate analysis of a prospectively collected database. We then build machine learning models for outcomes prediction. Results: We identified 596 patients. The rate of recurrence was 22.17%, that of thromboembolism was 0.9% and that of mortality was 14.78%. Smoking, platelet dysfunction, CKD, and alcohol use were independent predictors of higher recurrence, while resolution of the SDH was protective. OAC use had higher odds of developing TEEs. CKD, developing a new neurological deficit or a TEEs were independent predictors of higher mortality. We find the optimal time of resuming OAC to be after 2 days but before 21 days as these patients had the lowest recurrence of bleeding associated with a low risk of stroke. The ML model achieved an accuracy of 93, precision of 0.84 and recall of 0.80 for recurrence prediction. ML models for hospital stay performed poorly (R 2 = 0.33). ML model for stroke was overfitted given the low number of events. Conclusion: ML modeling is feasible. However, large well-designed prospective multicenter studies are needed for accurate ML so that clinicians can balance the risks of recurrence with the risk of TEEs, especially for high-risk anticoagulated patients.

Predicting Chronic Subdural Hematoma Resolution and Time to Resolution Following Surgical Evacuation

“…In our cohort, 47.5% of patients experienced hematoma resolution by 6 months after burr hole evacuation, of which the median surgery-to-resolution time was 161 days (IQR: 85–367); these metrics are similar to those reported in other recent studies ( 19 , 20 ). These results suggest that a large proportion of CSDH survivors continue to live with residual hematomas for several months or even years.…”

“…Though a direct investigation of correlations between hematoma resolution and long-term outcomes is outside the scope of this present study, we believe that characterizing CSDH resolution rates and their predictors serves an important intermediate step toward that end. In our cohort, 47.5% of patients experienced hematoma resolution by 6 months after burr hole evacuation, of which the median surgery-to-resolution time was 161 days (IQR: 85-367); these metrics are similar to those reported in other recent studies (19,20). These results suggest that a large proportion of CSDH survivors continue to live with residual hematomas for several months or even years.…”

Recommencement of anticoagulation/antiplatelet therapy following non-operative management of a Chronic Subdural Hematoma – Is there an optimal time frame?

“…A similar retrospective study of 596 patients following operative management found a recurrence rate of 22.17%. [ 13 ] This is significantly higher than the 5.88% found in the present study. This can be rationalized by the fact that patients with larger unstable hematomas with significant midline shift are prime candidates for operative management.…”

Minimally Invasive Surgery in Chronic Subdural Hematoma: Prognosis and Recurrence Factors of 516 Cases in a Single Center

“…In developing countries, the incidence reaches 0.0074% in the elderly group, accounting for nearly 10% of intracranial hemorrhage [ 4 ]. Moreover, elderly patients have a 10-fold increase in the risk of developing CSDH depending on their anticoagulation status [ 5 ]. Because of the increasing rise towards life expectancy and population aging, higher incidence and diagnostic innovation bring new challenges to our treatments.…”