2072 High Prevalence of Inappropriate Antithrombotic Use in Patients Presenting with Chronic Subdural Hematomas: Can We Prevent the Subdural Tsunami?

INTRODUCTION: Antithrombotic (AT) therapy is common among chronic subdural hematoma (cSDH) patients, potentially representing a risk factor for cSDH development and progression. METHODS: A multicenter retrospective review of cSDH patients who underwent surgical intervention and/or MMAe between 2019 and 2023 was conducted. Demographic data, presenting clinical/radiographic findings, AT indications/types, and post-treatment outcomes were extracted. Appropriateness of AT use was assessed according to clinical guidelines. RESULTS: A cohort of 224 (26.8% female, 73.2% male; mean age 69.9 ± 12 years) underwent surgery alone (81.3%) or surgery plus MMAe (18.8%). 38.4% were on AT therapy, with 30.2% on anticoagulants alone, 43.0% on antiplatelets alone, and 26.7% on both. Agents included warfarin (19.8%), direct oral anticoagulants (24.4%), low molecular weight heparin (12.8%), aspirin (51.2%), clopidogrel (8.1%), and dual antiplatelet therapy (DAPT; 10.5%). Indication for AT included atrial fibrillation (26.7%), venous thromboembolism (25.6%), coronary artery disease (24.4%), intra-arterial stents (10.5%), secondary stroke prevention (10.5%), and others (2.3%). After referencing clinical guidelines, 16.3% of patients were deemed inappropriately on AT therapy. On multivariate analysis, secondary stroke prevention (OR 5.62, 95% CI 1.26-25.30, p=0.024), and DAPT (OR 7.3, 95% CI 1.40-37.95 p=0.018) were associated with inappropriate AT use. No differences in hospital length of stay, 30-day mortality, readmission, or reoperation for hematoma recurrence between AT patients and those not on AT were observed. However, patients not on AT had higher odds of >50% reduction in target hematoma at time of discharge (OR 1.95, 95% CI 1.12-3.43, p=0.019). CONCLUSIONS: A significant number of cSDH patients were inappropriately using AT medications, with secondary stroke prevention and DAPT regimen being independent predictors for such use. Patients not on AT therapy had better radiographic outcomes at discharge, emphasizing the importance of eliminating unnecessary AT use as a potential means of primary prevention of cSDH.