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Chronic Subdural Hematoma
Insights
Managing antithrombotic drugs in patients with chronic subdural hematoma (cSDH) requires careful consideration. Discontinuing these medications increases thrombotic complication risks, necessitating individualized treatment plans.
Area of Science:
- Neurosurgery
- Geriatrics
- Pharmacology
Background:
- Chronic subdural hematoma (cSDH) primarily affects the elderly.
- Neurosurgical evacuation is standard for significant hematomas.
- Current guidelines lack clear recommendations for managing antithrombotic therapy in cSDH patients.
Purpose of the Study:
- To review existing literature on antithrombotic management in cSDH.
- To present findings from a cohort study on cSDH surgery patients.
- To inform clinical decision-making regarding antithrombotic therapy continuation or discontinuation.
Main Methods:
- Systematic literature search (Jan 2015-Oct 2020) in PubMed and EMBASE.
- Retrospective cohort study of 395 patients undergoing cSDH surgery (Oct 2014-Dec 2019).
- Analysis of outcomes related to antithrombotic drug management.
Main Results:
- Literature findings on thromboembolic risks are heterogeneous.
- Four of seven comparative studies showed significant differences in thromboembolic risk based on antithrombotic use/discontinuation.
- In the cohort study, 9.1% of patients experienced thrombotic complications after antithrombotic discontinuation.
Conclusions:
- Antithrombotic management in cSDH patients must be individualized.
- Early reinitiation of antithrombotics or surgery under continued therapy should be considered for high-risk patients.
Background:
Chronic subdural hematoma (cSDH) is typically a disease that affects the elderly. Neurosurgical evacuation is generally indicated for hematomas that are wider than the thickness of the skull. The available guidelines do not address the common clinical issue of the proper management of antithrombotic drugs that the patient has been taking up to the time of diagnosis of the cSDH. Whether antithrombotic treatment should be stopped or continued depends on whether the concern about spontaneous or postoperative intracranial bleeding, and a presumably higher rate of progression or recurrence, with continued medication outweighs the concern about a possibly higher rate of thrombotic complications if it is stopped.
Methods:
In this article, we review publications from January 2015 to October 2020 addressing the issue of the management of antithrombotics in patients with cSDH that were retrieved by a selective search in the Pubmed and EMBASE databases, and we present the findings of a cohort study of 395 patients who underwent surgery for cSDH consecutively between October 2014 and December 2019.
Results:
The findings published in the literature are difficult to summarize concisely because of the heterogeneity of study designs. Among the seven studies in which a group of patients on antithrombotics was compared with a control group, four revealed significant differences with respect to the risk of thromboembolic complications depending on previous antithrombotic use and the duration of discontinuation, while three others did not. In our own cohort, discontinuation of antithrombotics (including both plasmatic and antiplatelet drugs) was associated with thrombotic complications in 9.1% of patients.
Conclusion:
These findings imply that the management of antithrombotics should be dealt with critically on an individual basis. In patients with cSDH who are at elevated risk, an early restart of antithrombotic treatment or even an operation under continued antithrombotic therapy should be considered.
