Subdural Hematoma Risk in Patients on Antiplatelet and Anticoagulant Therapy: An Analysis Using Real-World Evidence

Introduction: Antiplatelet and anticoagulation therapy is widely used for treatment and prevention of various medical conditions. However, there remains on-going debate regarding the safest medication, particularly considering the increased risk of intracranial hematomas. Our study aims to use real-world evidence to analyze the odds of developing a subdural hematoma among patients prescribed antiplatelet or anticoagulant therapy, compared to the general population.

Methods: Data was gathered from a national electronic health records database containing de-identified electronic medical records from nearly 5 million patients in the United States receiving psychiatric, mental health, and counseling care. Patients were isolated by diagnosis history using International Classification of Disease, 10th revision (ICD-10) codes. Contingency tables were created to compare the incidence of subdural hematomas (ICD-10: S06.5-S06.599, I62.01) between patients prescribed antiplatelets or anticoagulant and those who were not. Antiplatelet medications analyzed include aspirin and clopidogrel, while anticoagulant medications examined were warfarin, low molecular weight heparin (LMWH), rivaroxaban, and apixaban. Odds ratios and confidence intervals (CI) were calculated to assess the relationship between subdural hematoma diagnosis and each drug.

Results: All calculated odds ratios were statistically significant. Patients on antiplatelet therapy had an increased odds of developing a subdural hematoma, with odds ratios of 1.76 for aspirin (95% CI: 1.68-1.83) and 2.25 for clopidogrel (95% CI: 2.10-2.41). Among anticoagulants, the odds ratios were 2.92 for warfarin (95% CI: 2.67-3.19), 5.34 for LMWH (95% CI: 4.21-6.27), 1.96 for rivaroxaban (95% CI: 1.74-2.20), and 2.57 for apixaban (95% CI: 2.37-2.79).

Conclusion : Antiplatelet agents should be prescribed cautiously in patients with an increased risk for subdural hematomas (fall risk, occupation, etc.). When anticoagulation is required, clinicians should consider transitioning from warfarin and LMWH to rivaroxaban, with a preference over apixaban, for long-term management. Additionally, alternative forms of venous thromboembolism prophylaxis should be considered for patients at elevated risk of intracranial bleeding.