Tranexamic acid with surgery vs. surgery alone for chronic subdural hematoma: Propensity score-matched analysis

Background: Chronic subdural hematoma (CSDH) is frequently managed with surgical evacuation, but recurrence often necessitates repeat surgery. Tranexamic acid (TXA), an antifibrinolytic agent, has been proposed as an adjunct to reduce rebleeding and recurrence. Data on its benefits and risks remain limited. Methods: Using a federated electronic health record network (TriNetX), we identified adults (≥18 years) with CSDH who underwent surgical evacuation. Patients who received TXA within 14 days of CSDH (TXA group) were compared with those managed without TXA (surgery-alone group). Outcomes were assessed at 6-months. Propensity score matching (1:1) was performed. Results: Of 15,423 eligible patients, 541 received TXA and 14,882 underwent surgery alone. After matching, 442 patients remained in each group. TXA was associated with a similar rate of needing repeat surgery (8.4 % vs. 9.5 %; OR, 0.870; 95 % CI, 0.548–1.382; P = 0.556). Secondary analysis showed significantly higher mortality rates in the TXA group (29.2 % vs. 14.0 %; OR, 2.526; 95 % CI, 1.802–3.541; P < 0.001), and a non-significant trend toward more thromboembolic events, including pulmonary embolism and deep vein thrombosis (9.3 % vs. 6.8 %; OR, 1.404; 95 % CI, 0.860–2.293; P = 0.173). Conclusions: TXA as an adjunct to surgical evacuation of cSDH was not associated with different rates of disease recurrence requiring repeat surgery. Analyses of secondary outcomes showed that TXA was associated with numerically higher rates of DVT/PE and significantly higher mortality.