Antiplatelet and Anticoagulation Use and Outcomes Following Chronic Subdural Hematoma Drainage: Systematic Review and...

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. A significant percentage of CSDH patients are on antiplatelet or anticoagulation therapy at baseline. Despite this, the impact of preoperative antiplatelet and anticoagulation therapy on outcomes following CSDH evacuation, specifically the risk of recurrence and thromboembolic events, remain unclear.

A search was conducted in MEDLINE (1946 to February 6, 2025), Embase (1974 to February 6, 2025), and PubMed (up to February 7, 2025) on preoperative use of antiplatelet (AP) or anticoagulation (AC) therapy and outcomes following surgical evacuation of CSDH.

Our literature search identified 3227 studies, out of which 47 were included. There were 16,288 patients included for analysis. Most patients (77%) in the AP group are on aspirin, and most patients in the AC (76%) group are on warfarin. AC use is associated with a significantly increased risk of hematoma recurrence (risk ratio [RR] 1.42, P = 0.002) and acute postoperative hemorrhage (RR 2.50, P = 0.002). AP use was also associated with increased recurrence (RR = 1.141, P = 0.22) and acute hemorrhage (RR 1.45, P = 0.23) though the effects were more modest and uncertain. Both AP (RR 2.98, P = 0.002) and AC (RR 3.04, P = 0.0007) had significantly higher thromboembolic complications in the perioperative period. Mortality was not significantly different, though it approached significance (P = 0.08) for the AC group.

Clinicians need to weigh the risk of hemorrhage against thromboembolism when deciding when managing antithrombotic therapy for patients undergoing evacuation of CSDH.