Timing of Restarting Anticoagulation and Antiplatelet Therapies After Traumatic Subdural Hematoma—A Single Institution Experience

Naylor, Ryan M.; Dodin, Rakan E.; Henry, Katharine; Peña, Nicole M. De La; Jarvis, Tyler L.; Labott, Joshua R.; Gompel, Jamie J. Van

doi:10.1016/j.wneu.2021.02.135

Cited by 12 publications

(5 citation statements)

References 18 publications

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“…40 Furthermore, the current literature empha-sizes thromboembolism in the setting of ATT withdrawal with a clear paucity of consideration for additional risks incurred by active reversal rather than passive cessation in neurosurgical intervention. 41 Although our data were insufficient for further statistical analysis, adverse events following reversal were most common in patients prescribed warfarin or multiple ATT medications, certainly contributing to the significantly increased mortality of this group.…”

Section: Discussionmentioning

confidence: 84%

The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

Dang,

Mugge,

Ramanathan

et al. 2023

Neurosurgical Focus

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OBJECTIVE The optimal perioperative management of antithrombotic therapy (ATT) in patients requiring urgent neurosurgical intervention for subdural hematoma (SDH) is poorly understood. The delicate equilibrium of effective hemostasis while preventing thrombosis is complex and relies on numerous factors such as indication for and type of ATT, medical comorbidities, and extent of neurological injury. This study aimed to analyze the impact of ATT and reversal strategies on surgical outcomes to highlight current challenges in the management of these high-risk patients. METHODS The authors performed a retrospective surgical cohort analysis of 100 patients undergoing urgent SDH evacuation at a level I trauma center between March 2020 and May 2021. The patients were first stratified into two cohorts based on preoperative ATT use and then further segregated by receipt of reversal agents. Statistical analysis included the chi-square test, Welch two-sample t-test, and multivariate logistic regression. The primary outcome was mortality. Secondary endpoints included radiographic SDH reexpansion, revision surgery, improvement in preoperative neurological deficits, and incidence of thromboembolism. A crossover cohort was secondarily analyzed in patients for whom ATT was interrupted for a minimum duration equal to effective drug metabolism. Finally, ATT reinitiation patterns were examined. RESULTS Of 100 patients, 48% received ATT, 54.2% of whom were given reversal agents. ATT use was significantly associated with decreased rates of postoperative neurological improvement (p = 0.023) with trends toward increased mortality (p = 0.078), SDH reexpansion (p = 0.12), and need for revision surgery (p = 0.10). Patient crossover revealed a 4 times greater likelihood of death in patients without ATT interruption prior to surgery (p = 0.040) without an observable impact on secondary outcomes. ATT reversal contributed no improvement in outcomes other than a decreased intensive care unit length of stay when adjusted for in-hospital mortality (p = 0.014). The rate of postoperative thromboembolism following ATT reversal was 11.5%. ATT reinitiation was highly variable, occurring in 59.5% of patients, with median times of 17 and 15 days for antiplatelets and anticoagulants, respectively. CONCLUSIONS Use of preoperative ATT portends poor clinical outcomes following nonelective SDH evacuation regardless of attempts to reverse these medications with replacement blood products. This study further reinforces the critical need for judicious use of ATT and optimization of reversal strategies in high-risk patient populations as best guided by multidisciplinary teams and evolving clinical practice guidelines.

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Section: Discussionmentioning

confidence: 84%

The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

Dang,

Mugge,

Ramanathan

et al. 2023

Neurosurgical Focus

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“…18 Naylor et al in their cohort of patients didn't find any increased rate of unplanned haematoma evacuation in patients with traumatic subdural haemorrhage who needed antiplatelet/ anticoagulant therapy. 19 Zanaty et al have performed a machine learning analysis and found that restarting antithrombotics after 2 days and within 21 days of surgery is associated with the lowest recurrence of bleed and low stroke rate in patients of CSDH. 20…”

Section: Discussionmentioning

confidence: 99%

Ischaemic Stroke After Chronic Subdural Haematoma: An Uncommon Complication in a Common Disease

Datta,

Chatterjee

2023

Journal of Stroke Medicine

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Background Chronic subdural haematoma (CSDH) is a common neurosurgical disease, particularly among the elderly, especially those on antiplatelet or anticoagulation with trivial trauma. While anticoagulants/antiplatelets increase the chance of rebleeding in cases of CSDH, discontinuation may increase the risk of stroke in these patients. Case Description: We report two cases of CSDH in elderly patients with risk factors who suffered from an ischaemic stroke after undergoing surgery. The first case was an elderly gentleman who had a history of percutaneous coronary intervention, presenting with a CSDH. He developed an anterior cerebral artery infarct in the immediate postoperative period. The second was an elderly gentleman with a history of hypertension presenting with a concomitant left thalamic infarct and large left-sided CSDH. He developed a second middle cerebral artery infarct of the opposite side in the immediate postoperative period. Conclusion: The medications used for stroke prophylaxis, that is, antiplatelets and anticoagulants are predisposing factors for the development of CSDH. However, the perioperative period of these patients remains vulnerable to the development of new-onset ischaemic stroke.

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“…Before restarting anticoagulants, several factors should be considered, including the severity of the TBI, the patient's bleeding status, and the real need for anticoagulation. Puckett et al [108] and Naylor et al [109] conducted retrospective studies on patients with TBI, claiming that adverse events were minimal when therapy was restarted 7-9.5 days and 30 days after the injury, respectively. In a multicenter, prospective, observational study, Matsushima et al [110] found that the re-initiation of OAT within 30 days after TBI was associated with a higher risk of TBI progression, too.…”

Section: Prophylaxis and Anticoagulant Resumption After Tbimentioning

confidence: 99%

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

Menditto,

Rossetti,

Sampaolesi

et al. 2024

JCM

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The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a “take home message” is stated.

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Timing of Restarting Anticoagulation and Antiplatelet Therapies After Traumatic Subdural Hematoma—A Single Institution Experience

Cited by 12 publications

References 18 publications

The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

The implications of antithrombotic agents on subdural hematoma evacuation: what does "reversal" truly entail?

Ischaemic Stroke After Chronic Subdural Haematoma: An Uncommon Complication in a Common Disease

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

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