Time to Resume Oral Anticoagulant Therapy in Traumatic Intracranial Hemorrhage Patients, Balancing Recurrence, Thromboembolism, and Mortality: A Systematic Review.

OBJECTIVE

Managing patients on oral anticoagulant therapy (OAC) who present with traumatic intracranial hemorrhage (ICH) poses a critical challenge in balancing the prevention of thromboembolic events and the risk of progression or recurrent ICH. The objective of this systematic review was to determine the optimal timing for resuming OAC in patients with traumatic ICH, and to assess the risk of hemorrhagic and thromboembolic events, and mortality in patients for whom anticoagulation was resumed.

DESIGN

With a medical librarian, 4 databases and gray literature were searched without language or date restrictions.

PARTICIPANTS AND MAIN MEASURES: Eligible studies included patients with traumatic ICH undergoing OAC resumption and reporting on timing, ICH progression or recurrence, thromboembolic events, and/or mortality.

RESULTS

Of 3384 identified studies, 12 cohort studies met inclusion criteria, involving 13,528 patients with varying severities of traumatic brain injury. Most patients were treated with vitamin K antagonists; only 3 studies included patients on direct oral anticoagulants. The median time to resume OAC ranged from 8 to 67 days. In studies limited to traumatic ICH, OAC resumption was not associated with increased recurrent ICH risk with reported RR 0.70 (95% CI, 0.52-0.95) and HR 0.45 (95% CI, 0.26-0.76). All but one study reported reduced thromboembolic events with OAC resumption. The studies also suggested that complete resolution of the initial ICH allowed for safe resumption of OAC.

CONCLUSIONS

This systematic review suggests that resumption of OAC after traumatic ICH may be considered in selected patients, without a clear evidence of increase in the risk of recurrent ICH and with a potential reduction in thromboembolic events. However, we were unable to define a safe timeframe, and further studies are needed to establish recommendations to guide clinical practice.

LEVEL OF EVIDENCE: Level III, Systematic Review and Meta-Analysis.