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

BACKGROUND: The periprocedural management of antithrombotic medications in patients with chronic subdural hematoma (cSDH) after middle meningeal artery embolization (MMAE) or surgical evacuation is uncertain. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.