Perioperative Management of Chronic Subdural Hematoma Under Antithrombotic Therapy: A Multicenter Analysis of 679 Patients

BACKGROUND AND OBJECTIVES: – Management of chronic subdural hematoma (cSDH) in elderly patients receiving antithrombotic therapy remains heterogeneous, and surgical evacuation is often delayed allowing partial pharmacological washout despite limited supporting evidence. The aim of this study was to determine whether a structured perioperative pathway permits safe evacuation of cSDH as soon as logistically feasible, without awaiting drug washout, and to evaluate differences in recurrence probability and timing across antiplatelet, anticoagulant, and nonantithrombotic cohorts.METHODS: – A multicenter retrospective analysis was conducted on consecutive elderly patients treated through a shared perioperative management. Patients were stratified into antiplatelet therapy (Group A, n = 199), anticoagulant therapy (Group B, n = 254), and no antithrombotic therapy (Group C, n = 226). Early recurrence rates were compared using predefined ±10% equivalence margins. Independent predictors of recurrence probability were identified using multivariate logistic regression analysis, and determinants of recurrence timing were assessed with Cox proportional hazards model.RESULTS: – Early recurrence occurred in 9.0% of Group A, 11.8% of Group B, and 13.7% of Group C, with no significant differences among groups. Equivalence testing confirmed that recurrence rates met predefined equivalence criteria across all pairwise comparisons. Mean time to recurrence differed significantly (P = .023), with earlier recurrence in antiplatelet-treated patients. In the multivariate logistic regression model, postoperative length of stay was the only independent predictor of recurrence probability (P < .001). In the Cox model, antiplatelet therapy (hazard ratio 3.387, P < .001) and a history of stroke (hazard ratio 2.726, P = .034) independently influenced recurrence timing, whereas pharmacological status did not increase recurrence incidence. Complication rates were comparable across groups, and no thromboembolic events were observed.CONCLUSION: – A shared perioperative pathway allowed cSDH evacuation as soon as logistically feasible while maintaining comparable early recurrence rates across antiplatelet, anticoagulant, and nonantithrombotic groups, despite differences in time to recurrence. Distinct predictors of recurrence probability and timing support the feasibility and clinical relevance of immediate surgical treatment within a coordinated perioperative framework. © Congress of Neurological Surgeons 2026. All rights reserved.