To discuss the clinical course and management to patients who developed anticoagulation-related subdural hematoma (SDH) and underwent middle meningeal artery (MMA) embolization and successful re-initiation of anticoagulation therapy.

A common risk factor of non-traumatic SDH is anticoagulation therapy. Anticoagulation is generally held in patients who develop SDH, but may lead to thromboembolic events. There remains little evidence regarding ongoing anticoagulation treatment.

Direct clinical management with retrospective chart review.

Patient 1 is a 69-year-old male with history of atrial fibrillation on warfarin. He developed progressive headache. CT head demonstrated bilateral SDH. He underwent bilateral evacuation and therapeutic anticoagulation was held. Repeat CT head 3 months later demonstrated bilateral SDH, and transesophageal echocardiogram revealed a left atrial appendage thrombus. He underwent bilateral MMA embolization. CT head 10 days later showed improvement in SDH. Therapeutic anticoagulation was initiated with heparin, with transition to warfarin. CT head at time of therapeutic INR demonstrated decreased SDH.

Patient 2 is an 81-year-old male with a history of saphenous vein thrombosis who presented with a progressive headache. He was found to have extensive cerebral venous sinus thrombosis (CVST) and he was initiated on warfarin. Four months later, MR venogram showed residual thrombus. An incidental right SDH was found at that time. Warfarin was discontinued and CVST subsequently increased. He was given therapeutic enoxaparin and underwent right MMA artery embolization. Afterwards, he was transitioned to warfarin. Repeat CT head after initiation of anticoagulation showed stability of SDH.

Endovascular MMA embolization  followed by re-initiation of anticoagulation may be an effective adjunct therapy for clinical scenarios in patients with SDH and an urgent indication for anticoagulation. Longer follow-up, prospective series, and future randomized clinical trials are needed to objectively assess outcomes in this clinically challenging patient population.