Dtsch Arztebl Int. 2022 Mar 25;119(12):208-213. doi: 10.3238/arztebl.m2022.0144.
Chronic subdural hematoma (cSDH) is typically a disease that affects the elderly. Neurosurgical evacuation is generally indicated for hematomas that are wider than the thickness of the skull. The available guidelines do not address the common clinical issue of the proper management of antithrombotic drugs that the patient has been taking up to the time of diagnosis of the cSDH. Whether antithrombotic treatment should be stopped or continued depends on whether the concern about spontaneous or postoperative intracranial bleeding, and a presumably higher rate of progression or recurrence, with continued medication outweighs the concern about a possibly higher rate of thrombotic complications if it is stopped.
In this article, we review publications from January 2015 to October 2020 addressing the issue of the management of antithrombotics in patients with cSDH that were retrieved by a selective search in the Pubmed and EMBASE databases, and we present the findings of a cohort study of 395 patients who underwent surgery for cSDH consecutively between October 2014 and December 2019.
The findings published in the literature are difficult to summarize concisely because of the heterogeneity of study designs. Among the seven studies in which a group of patients on antithrombotics was compared with a control group, four revealed significant differences with respect to the risk of thromboembolic complications depending on previous antithrombotic use and the duration of discontinuation, while three others did not. In our own cohort, discontinuation of antithrombotics (including both plasmatic and antiplatelet drugs) was associated with thrombotic complications in 9.1% of patients.
These findings imply that the management of antithrombotics should be dealt with critically on an individual basis. In patients with cSDH who are at elevated risk, an early restart of antithrombotic treatment or even an operation under continued antithrombotic therapy should be considered.
慢性硬脑膜下血肿（cSDH）通常是一种影响老年人的疾病。对于厚度超过颅骨的血肿，一般建议进行神经外科清除。现有的指南并未解决患者在 cSDH 诊断时正在服用的抗血栓药物的合理管理这一常见临床问题。是否停止或继续抗血栓治疗取决于对自发性或术后颅内出血的担忧，以及继续用药可能导致更高的进展或复发率，与因停止治疗而导致更高的血栓并发症风险相比，是否更值得关注。
本文通过在 Pubmed 和 EMBASE 数据库中进行选择性搜索，回顾了 2015 年 1 月至 2020 年 10 月期间发表的关于 cSDH 患者抗血栓药物管理问题的文献，并报告了 2014 年 10 月至 2019 年 12 月期间连续接受 cSDH 手术的 395 例患者的队列研究结果。
由于研究设计的异质性，文献中的研究结果难以简洁地总结。在七项比较抗血栓药物组与对照组患者的研究中，四项研究表明，根据既往抗血栓药物使用情况和停药时间，血栓栓塞并发症的风险存在显著差异，而另外三项研究则没有。在我们自己的队列中，停用抗血栓药物（包括血浆和抗血小板药物）与 9.1%的患者发生血栓并发症相关。
这些发现表明，抗血栓药物的管理应根据个体情况进行严格处理。对于 cSDH 患者中存在高风险的患者，应考虑早期重新开始抗血栓治疗，甚至在继续抗血栓治疗的情况下进行手术。
