Preoperative angiotensin converting enzyme inhibitor usage in patients with chronic subdural hematoma: Associations with initial presentation and clinical outcome

• Preoperative ACE inhibitor usage was associated with higher initial hematoma volume in patients with cSDH.
• Reintervention rates were higher in patients preoperatively on ACE inhibitors.
• This latter observation was even more pronounced in the very old (>80 years).

The aim of this study is to analyze the association of preoperative usage of angiotensin converting enzyme (ACE) inhibitors with the initial presentation and clinical outcome of patients with chronic subdural hematoma (cSDH). Patients treated for cSDH between 2009 and 2013 at our institution were included in this retrospective case-control study. Medical charts were reviewed retrospectively and data were analyzed using descriptive and inferential statistics. Out of 203 patients (58 females, mean age 73.2 years), 53 (26%) patients were on ACE inhibitors before their presentation with cSDH. Median initial hematoma volume in individuals with ACE inhibitors (179.2 ± standard error of the mean [SEM] 13.0 ml) was significantly higher compared to patients without ACE inhibitors (140.4 ± SEM 6.2 ml; p = 0.007). There was an increased probability of surgical reintervention in the ACE inhibitor group (12/53, 23% versus 19/153, 12%; p = 0.079), especially in patients older than 80 years (6/23, 26% versus 3/45, 7%; p = 0.026). ACE inhibitors are associated with higher hematoma volume in patients with cSDH and with a higher frequency of recurrences requiring surgery (especially in the very old). We hypothesize that these effects are due to ACE inhibitor induced bradykinin elevation causing increased vascular permeability of the highly vascularized neomembranes in cSDH.