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Anticoagulation and Antiplatelet Therapy in Chronic Subdural Hematoma: A Multicenter Evaluation
Asfand Baig Mirza1,2, Sami Rashed1, Ariadni Georgiannakis3
1Department of Neurosurgery, Queens Hospital, Romford , UK.
Insights
Anticoagulant and antiplatelet (ACAP) use in chronic subdural hematoma (cSDH) patients did not increase reoperation risk. Stopping ACAP medications longer preoperatively or restarting them earlier postoperatively did not significantly alter reoperation rates.
Area of Science:
- Neurosurgery
- Geriatric Medicine
- Clinical Pharmacology
Background:
- Chronic subdural hematomas (cSDH) are common in elderly patients, often with comorbidities.
- Many older adults use anticoagulant and antiplatelet (ACAP) medications, complicating cSDH management.
- Clinicians must balance stopping ACAP drugs against bleeding risks in cSDH.
Purpose of the Study:
- To analyze outcomes of ACAP use in cSDH patients.
- To investigate the impact of ACAP management on reoperation, mortality, and neurological function.
- To evaluate the association between ACAP discontinuation/reinitiation and cSDH outcomes.
Main Methods:
- Retrospective study of 1355 cSDH patients across 5 UK neurosurgical units (2011-2023).
- Collected data on comorbidities, ACAP use, surgical management, reoperation, mortality, and functional status.
- Statistical analysis included multivariable logistic regression and Kaplan-Meier analysis for reoperation rates.
Main Results:
- Patients on ACAP (n=657) had higher crude reoperation rates (12.2%) than those not on ACAP (n=798, 8.8%), but this was not significant after multivariable adjustment (OR=1.41, P=.272).
- Longer preoperative ACAP discontinuation and earlier postoperative reinitiation did not significantly affect reoperation rates.
- ACAP patients had significantly worse functional outcomes (mRS 0-2: 52.4% vs 66.4%, aOR=0.69, P=.007).
Conclusions:
- Preoperative ACAP use and extended discontinuation are not independently linked to increased cSDH reoperation risk.
- Earlier postoperative ACAP reinitiation shows no significant association with reoperation risk.
- Further large-scale prospective studies are needed to guide clinical recommendations regarding ACAP management in cSDH.
Background And Objectives:
Chronic subdural hematomas (cSDH) are among the most common neurosurgical pathologies. Older adults also often have comorbidities treated with anticoagulant and antiplatelet (ACAP) medications. Managing clinicians frequently must weigh the benefits and risks of stopping and reinitiating such drugs in cSDH. The aim of this retrospective study was to analyze outcomes associated with ACAP use and cSDH, focusing on the need for reoperation, mortality, and neurological function.
Methods:
Between 2011 and 2023, patients requiring surgical management of a cSDH across 5 UK neurosurgical units were identified. Collected variables included patient comorbidities, preoperative and postoperative neurological function, ACAP termination and reinitiation, need for reoperation, and mortality. Statistical analysis included multivariable logistic regression for predictors of key outcomes; reoperation, functional status, and mortality including a Kaplan-Meier analysis for reoperation rates based on different ACAP treatments.
Results:
One thousand three hundred fifty-five patients underwent analysis, of which 245 were on anticoagulants, 277 were on antiplatelets, 35 were on dual ACAP medications, and 798 were not on any previous ACAP therapy. The median age was 75 years (IQR = 66-83), and the overall reoperation rate was 10.2% (n = 68 on ACAP and n = 70 on no ACAP treatment). Patients on ACAP had higher crude reoperation rates (12.2% vs 8.8%, P = .049), though this difference was not significant after multivariable adjustment (odds ratio = 1.41, 95% CI, 0.77-2.55, P = .272). Discontinuing ACAP treatment for longer preoperatively and later reinitiation did not significantly affect reoperation rates. ACAP patients were generally more comorbid and had significantly worse functional outcomes (modified Rankin Scale 0-2: 52.4% vs 66.4%, adjusted odds ratio = 0.69, 95% CI, 0.53-0.91, P = .007).
Conclusion:
Preoperative ACAP use and longer preoperative discontinuation are not independently associated with increased reoperation risk in patients with cSDH. Earlier postoperative ACAP reinitiation is also not significantly associated with reoperation risk. However, more extensive large scale prospective studies are required to support these findings and form clinical recommendations.
