Clinical Scorecard: Impact of Antithrombotic Treatment on Recurrence and Outcomes of Chronic Subdural Hematoma Following Burr-Hole Craniostomy in a Community-Based Cohort

At a Glance

Key Highlights

• CSDH incidence increases significantly with age, reaching up to 129.5/100,000/year in those aged ≥80 years
• Antithrombotic therapy (ATT) was used by 54.5% of patients at diagnosis but was not associated with increased hematoma recurrence after burr-hole craniostomy
• Hematoma recurrence requiring reoperation occurred in 15.8% of patients; overall 3-year mortality was 27.9%

Guideline-Based Recommendations

Diagnosis

• Use Glasgow Coma Scale (GCS) and Markwalder Grading Scale (MGS) to assess symptom severity on admission
• Perform routine control CT scan 1 month post-surgery or earlier if clinical deterioration occurs
• Define hematoma recurrence as symptomatic CSDH in the same location requiring reoperation within 6 months

Management

• Surgical treatment via single burr-hole craniostomy with intraoperative saline irrigation and closed subdural drainage
• Temporary discontinuation of antithrombotic therapy perioperatively with resumption permission from neurosurgical unit
• Consider local anesthesia to enable surgery in frail and comorbid patients

Monitoring & Follow-up

• Radiological follow-up beyond 1 month if clinically significant residual hematoma is present
• Monitor for hematoma recurrence up to 6 months postoperatively
• Assess mortality outcomes up to 3 years post-surgery

Risks

• Evaluate bleeding risk using HAS-BLED score; ≥3 indicates high bleeding risk
• Evaluate thromboembolic risk using CHA2DS2-VASc score; ≥2 indicates high thromboembolic risk
• Balance risk of thromboembolic events against bleeding risk when managing antithrombotic therapy

Patient & Prescribing Data

301 patients undergoing burr-hole craniostomy for CSDH, mean age 76.6 years, 66.4% male

54.5% used antithrombotic therapy at diagnosis, primarily warfarin and low-dose aspirin; ATT did not increase recurrence risk but delayed resumption was associated with recurrence

Clinical Best Practices

• Perform burr-hole craniostomy with saline irrigation and closed drainage for symptomatic CSDH
• Temporarily discontinue antithrombotic therapy perioperatively with careful timing of resumption
• Use standardized scales (GCS, MGS, mRS) for clinical assessment and follow-up
• Conduct routine imaging follow-up at 1 month and extend as clinically indicated
• Assess bleeding and thromboembolic risks individually to guide antithrombotic management

References

• HAS-BLED Score for Bleeding Risk
• CHA2DS2-VASc Score for Thromboembolic Risk
• Glasgow Coma Scale
• Markwalder Grading Scale
• Modified Rankin Scale