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Characteristics of chronic subdural haematomas related to DOACs vs warfarin
Gokul Raj Krishna1, Aleksandra Sobieraj1, Sayan Biswas2
1Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England, M13 9PL, UK.
Insights
Direct oral anticoagulants (DOACs) may be safer than warfarin for chronic subdural hematomas (CSDHs), potentially leading to smaller hematomas and less midline shift. This finding is crucial for managing anticoagulated, aging populations.
Area of Science:
- Neurosurgery
- Pharmacology
- Geriatrics
Background:
- Chronic subdural hematomas (CSDHs) are a significant concern, particularly in aging populations requiring anticoagulation.
- The choice of anticoagulant, such as direct oral anticoagulants (DOACs) or warfarin, may influence CSDH characteristics and patient outcomes.
- Understanding these effects is vital for optimizing treatment strategies in a growing demographic of elderly and multi-morbid patients.
Purpose of the Study:
- To investigate the impact of DOACs versus warfarin on CSDH characteristics.
- To specifically analyze differences in hematoma size, midline shift, and Glasgow Coma Scale (GCS) scores.
- To evaluate the relative safety profiles of DOACs and warfarin in patients with CSDHs.
Main Methods:
- A multi-center retrospective case series analysis was conducted from January 2015 to May 2020.
- Included patients were those anticoagulated with either DOACs or warfarin presenting with CSDHs.
- Statistical analyses included chi-squared tests, independent t-tests, and relative risk calculations to compare CSDH size, midline shift, and GCS.
Main Results:
- A total of 2,675 patients were analyzed; 33.8% were on antithrombotic therapy (298 on warfarin, 203 on DOACs).
- Statistically significant associations were found between anticoagulant type and CSDH size and midline shift (p < 0.0001), but not GCS (p = 0.1956).
- DOACs demonstrated a potentially safer profile with lower relative risk for larger hematomas (RR 0.887 vs 1.021) and reduced midline shift (RR 0.858 vs 0.938) compared to warfarin.
Conclusions:
- DOACs may represent a safer anticoagulation strategy for CSDH patients compared to warfarin, associated with smaller hematomas and less midline shift.
- These findings suggest DOACs could potentially reduce the need for neurosurgical intervention for CSDHs.
- The results have significant implications for managing anticoagulation in the elderly and multi-morbid population presenting with CSDHs.
Objectives:
The aim of this study was to investigate the effects of anticoagulation with DOACs and warfarin on the characteristics of chronic subdural hematomas (CSDHs), specifically, the size of the hematomas, the presence of midline shift and the effect on consciousness levels, measured via the Glasgow Coma Scale (GCS).
Methods:
A multi-centre retrospective case series analysis from January 2015 to May 2020 was conducted. Patients who were anticoagulated with DOACs and warfarin were of primary interest. The CSDH characteristics that were focussed on included the size of the CSDH, midline shift and GCS. Chi-squared analysis and independent t-tests were conducted for inter-variable analysis. Relative risk was also calculated.
Results:
Two thousand, six hundred seventy-five patients across two tertiary neurosurgical units referred with CSDHs were included in the analysis. 1799 patients were male (67.3%), with a mean age of 78.5 years. 905 patients (33.8%) were on antithrombotic therapy, with 298 patients (11.1%) on warfarin and 203 patients (7.6%) on DOACs. There were statistically significant associations between the type of antithrombotic medication and both midline shift and size of the CSDH (p < 0.0001), but not GCS (p = 0.1956). No significant difference in relative risk (RR) for impaired GCS was found between DOACs and warfarin (1.158 vs 1.174 respectively). Relative risk analysis revealed a safer profile for DOACs, with a lower risk of developing a larger sized hematoma (RR 0.887 v 1.021) and a reduced likelihood of midline shift (RR 0.858 VS 0.938), which was supported by effect size analysis using odd's ratios. Comparative risk analysis between DOACs and warfarin further demonstrated a higher risk of midline shift for patients on warfarin (RR 1.431), that trended towards statistical significance (p = 0.0511, 95% confidence interval 0.998-2.05).
Conclusions:
For CSDH patients, DOACs may potentially be a safer method of anticoagulation as opposed to warfarin as they appear to be linked to the development of smaller sized hematomas and reduced midline shift, although there was no significant difference in GCS between the groups. These features are known to reduce the risk of needing neurosurgical intervention for CSDH. This is important in influencing the management of an increasingly ageing, multi-morbid population on increasing amounts of anticoagulation medication.
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