Reinitiating antiplatelet therapy in chronic subdural hematoma: Does adjunctive middle meningeal artery embolization improve outcomes?

The optimal timing for reinitiating antiplatelet therapy after treatment of chronic subdural hematoma (cSDH) remains uncertain, especially when middle meningeal artery embolization (MMAE) is used as an adjunct to surgery. This study evaluated the safety and outcomes of early antiplatelet reinitiation in patients undergoing combined surgical evacuation and MMAE, and compared outcomes in antiplatelet-treated patients receiving surgery with versus without MMAE. Adult cSDH patients from the TriNetX database (May 2020-May 2025) were identified using ICD-10 and RXNORM codes. Two propensity score-matched analyses were performed: (1) patients receiving surgery with adjunct MMAE, stratified by antiplatelet initiation within 30 days; and (2) antiplatelet-treated patients undergoing surgery with adjunct MMAE versus surgery alone. Outcomes included rescue surgery and 6-month mortality. After matching, early antiplatelet use in surgery + MMAE patients (n = 163 per group) was not associated with higher rescue surgery rates (OR 0.68, 95% CI 0.32-1.48) or mortality (OR 1.52, 95% CI 0.73-3.20). Among antiplatelet-treated patients, surgery + MMAE (n = 176) had similar rescue surgery rates to surgery alone (n = 176) but significantly lower mortality (10.8% vs. 21.0%; OR 0.46, 95% CI 0.25-0.83, p = 0.009). Early antiplatelet reinitiation appeared safe after cSDH evacuation with adjunct MMAE. The associated lower 6-month mortality with adjunct MMAE in antiplatelet-treated patients is observational and hypothesis-generating, and warrants prospective confirmation.