Reinitiating anticoagulation in chronic subdural hematomas: does adding middle meningeal artery embolization add value? A multi-institutional, multinational database study

Background The safety of early anticoagulation in chronic subdural hematoma (cSDH) patients treated with surgery, with or without middle meningeal artery embolization (MMAE), remains unclear. This study evaluates 6-month outcomes among cSDH patients who received early anticoagulation following surgery with adjunct MMAE and compares outcomes between anticoagulated patients treated with surgery alone versus surgery plus MMAE. Methods Patients aged ≥18 years with cSDH who underwent surgery alone or surgery plus MMAE and received anticoagulation were identified using the 10th revision of the International Classification of Diseases (ICD-10) and RXNORM codes on the TriNetX platform. Two analyses were performed: surgery plus MMAE cohort, stratified by anticoagulation use within 1 month; and anticoagulated patients, stratified by surgery alone versus surgery plus MMAE. Primary outcomes included repeat surgery and 6-month mortality; secondary outcomes included repeat intracranial hemorrhage and cerebral infarction. Results Among 801 patients treated with surgery plus MMAE, 143 received anticoagulation and 658 did not. In this cohort, no significant differences were observed in rates of repeat surgery (OR 1.00, 95% CI 0.403 to 2.483) or 6-month mortality (OR 0.557, 95% CI 0.245 to 1.263) between those who received anticoagulation and those who did not. When comparing 2301 patients who underwent surgery alone and received anticoagulation to the 143 patients who received anticoagulation following surgery plus MMAE, the latter group had significantly lower mortality (7.9% vs 19.4%; OR 0.356, 95% CI 0.169 to 0.751, P=0.005) and reduced rates of repeat intracranial hemorrhage (54.0% vs 66.9%; OR 0.580, 95% CI 0.357 to 0.942, P=0.027). Conclusion Early anticoagulation following surgery with adjunct MMAE appears safe and is associated with reduced mortality and hemorrhage risk compared with surgery alone in anticoagulated patients.