Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials

Abstract

Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.

Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review

“…Limited data are available on resuming anticoagulation after ICH [ 135 ]. Factors associated with a high risk of ICH recurrence include the mechanism of bleeding (spontaneous versus traumatic), lobar location, and presence/number of microbleeds on magnetic resonance imaging (suggestive of amyloid angiopathy) [ 133 ].…”

“…Optimal timing of anticoagulation resumption after ICH has been evaluated only in observational studies [ 135 , 139 ]. Current guidelines recommend discontinuing oral anticoagulation for at least 4 weeks in patients without high thrombotic risk (e.g., mechanical heart valves) [ 3 , 132 , 133 ].…”

Developing a National Trauma Research Action Plan: Results from the geriatric research gap Delphi survey

“…Traumatic brain injury is associated with higher rates of thromboembolic complications, especially among geriatric TBI patients. However, TBI is also associated with significant rates of intracranial hemorrhage, which may be worsened by continued anticoagulation regimens 44,45 . Thus, it is a critical decision for clinicians whether to temporarily stop anticoagulation for such patients, and how soon after the injury to resume anticoagulation.…”

“…However, TBI is also associated with significant rates of intracranial hemorrhage, which may be worsened by continued anticoagulation regimens. 44,45 Thus, it is a critical decision for clinicians whether to temporarily stop anticoagulation for such patients, and how soon after the injury to resume anticoagulation. In the national agenda for the geriatric population, the inclusion of TBI and its related set of outcomes and concepts should be a top priority.…”

Management of traumatic brain injury in older adults: What you need to know

“…[39][40][41] While there is a consensus that anticoagulation should be resumed, the timing remains uncertain. 42 The American Heart Association/ American Stroke Association's 2014 updated guidelines suggest an individualized approach based on the risk of subsequent thromboembolism, recurrent ICH, and overall patient status. The guidelines suggest the use of antiplatelet therapy instead of anticoagulation for those with a higher risk of recurrent ICH relative to cerebral infarction.…”