Timing of the resumption of antithrombotic agents following surgical evacuation of chronic subdural hematomas: a retrospective cohort study

Abstract

C hroniC subdural hematoma (cSDH) is a disease of the elderly and demonstrates an incidence of approximately 3.4 patients per 100,000 persons younger than 65 years of age and 8 to 58 patients per 100,000 persons older than 65 years. 1,4,9 The prevalence of cSDH is expected to rise as the percentage of the United States population older than 65 years grows from 12% in 2003 to a projected 20% by 2030. 17Other identified risk factors for the development of cSDH include male sex, history of falls, chronic alcohol use, and antiplatelet or anticoagulant therapy, with warfarin increasing the relative risk of developing cSDH by aBBreViatiONS ADP = adenosine diphosphate; ASA = acetylsalicylic acid; AT = antithrombosis; CAD = coronary artery disease; cSDH = chronic subdural hematoma; DVT = deep venous thrombosis; INR = international normalized ratio; LMWH = low-molecular-weight heparin; TIA = transient ischemic attack. OBJectiVe Antithrombosis (AT), defined here as either antiplatelets or anticoagulants, is a significant risk factor for the development of chronic subdural hematomas (cSDHs). Resuming AT following the evacuation of cSDH is a highly variable practice, with scant evidence in the literature for guidance. Here, a retrospective analysis of a cohort of patients from a single institution undergoing surgical drainage of cSDH was performed to evaluate postoperative complications and determine the optimal timing of the resumption of common antithrombotic agents. methOdS This retrospective analysis was performed on 479 patients undergoing surgical evacuation of cSDH at St. Michael's Hospital over a 5-year period (2007)(2008)(2009)(2010)(2011)(2012). The collected variables included the type of AT agent, indications for AT, timing and type of postoperative complications, and the restart intervals for the AT agents, when available. Postoperative complications were classified as major hemorrhages, minor hemorrhages, or thromboembolic events. reSultS Among all 479 study patients, 71 experienced major hemorrhage (14.8%), 110 experienced minor hemorrhage (23.0%), and 8 experienced thromboembolism (1.67%) postoperatively. Patients on any type of preoperative AT regimen were at a higher risk of major hemorrhage (19.0% vs 10.9%; OR 1.93; 95% CI 1.15-2.71; p = 0.014). The type of AT agent did not affect the frequency of any postoperative complications. Patients on any preoperative AT regimen experienced earlier postoperative major hemorrhages (mean 16.2 vs 26.5 days; p = 0.052) and thromboembolic events (mean 2.7 vs 51.5 days; p = 0.036) than those patients without a history of AT; the type of AT agent did not affect timing of complications. Patients who were restarted on any AT therapy postoperatively were at decreased risk of major rebleeding following resumption than those patients who were not restarted (OR 0.06; 95% CI 0.02-0.2; p < 0.01). cONcluSiONS Patients with a history of preoperative AT experienced thromboembolic complications significantly earlier than those patients without AT, which peaked at 3 days postoperative...

Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy

“…24,27 Early ASA resumption or even continued perioperative intake was shown to be safe for burr-hole drainage in chronic subdural hematoma (cSDH) as well as shunt placement. 9,10,14,15,17 To our knowledge, there are no randomized controlled trials (RCTs) analyzing bleeding risk with continued perioperative AP/AC treatment in neurosurgery. A protocol for an ongoing RCT of continued ASA treatment for patients undergoing surgical evacuation of cSDH has been published and the study is currently ongoing.…”

Resumption of antiplatelet therapy in patients with primary intracranial hemorrhage-benefits and risks: A meta-analysis of cohort studies

“…Of the remaining 17 articles, 9 were excluded because they were only about anticoagulants [24][25][26][27][28][29][30][31][32], one was excluded because the majority of participants who had resumed antithrombotic agents had their medicine terminated or changed during the follow-up [33], and one was excluded because there was no clear record of which kind of antithrombotic agents, oral anticoagulant, or AP therapy was resumed [34]. Finally, only 6 articles met the inclusion criteria [35][36][37][38][39][40]. The study selection is presented in flow chart form in Fig.…”

“…The 6 studies offered data containing 1916 patients (825 in AP resumption group, 1091 in non-AP resumption group) [35][36][37][38][39][40]. Pooled result using the random-effects model showed that there was no significant difference between AP resumption group and non-AP resumption group for ICH recurrence or hematoma expansion (RR, 0.84; 95% CI, 0.47-1.51; P = 0.56) (Fig.…”

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

“…One retrospective cohort study compared outcomes in those who restarted on their antithrombotic drugs to those who did not. 3 The researchers found similar risks of thromboembolism (unadjusted OR, 1.34; 95% CI, 0.29-6.13), but a lower risk of recurrence (unadjusted OR, 0.06; 95% CI, 0.02-0.20) in the antithrombotic restart group. This result, however, is limited by few outcome events in the study group and likely confounders that were not adjusted for.…”

“…1 Approximately 40% of patients with CSDH are taking an antithrombotic drug at the time of presentation. 2,3 A large, population-based case-control study has demonstrated an association between increasing antithrombotic drug use and increasing incidence of CSDH. 4 Perioperative management of antithrombotic drugs is therefore an important aspect for these patients.…”