Antithrombotic resumption after middle meningeal artery embolization or surgery for chronic subdural hematoma: a systematic review and meta-analysis.

Abstract

The periprocedural management of antithrombotic medications in patients with chronic subdural hematoma (cSDH) after middle meningeal artery embolization (MMAE) or surgical evacuation is uncertain. A systematic review was conducted across Medline, Embase, and Web of Science databases. We pooled proportions and risk ratios (RRs) for the meta-analysis with the corresponding 95% CIs. Systemic and intracranial (including recurrence) bleeding complications and thromboembolic events were evaluated. Of the 16 included studies with 4606 patients, 1784 were receiving antithrombotic medications. Antithrombotic therapy was resumed in 1231 patients (69.0%). Bleeding complications were similar between patients in whom antithrombotic therapy was resumed (14.1%, 95% CI 9.7% to 20.2%) and in those in whom it was discontinued (15.4%, 95% CI 7.4% to 29.3%). After MMAE, patients had similar rates of bleeding events (12.1%, 95% CI 4.9% to 27.0%) to patients with overall treated cSDH, and recurrence (RR 2.28, 95% CI 0.46 to 11.37) and reoperation (RR 1.07, 95% CI 0.40 to 2.917) risks were similar between the resumed and discontinued groups. Thromboembolic complications were significantly higher in the discontinued group (12.6%, 95% CI 6.5% to 23.0%) than in the resumption group (3.5%, 95% CI 1.8% to 6.9%). Earlier resumption (1 week to 1 month) was associated with a lower thromboembolic risk without increasing bleeding complications. Post-procedural antithrombotic resumption may reduce thromboembolic events without significantly increasing bleeding risk. Early resumption of antithrombotics post-MMAE appears to be safe, although further data are required to confirm this observation. Future studies should aim to better define patient characteristics influencing decision-making in this context.