Recommencement of anti-thrombotics following traumatic intracranial haemorrhage; a preliminary survey of UK consultant neurosurgeons informing the RESTART-tICrH trial design.

INTRODUCTION: Traumatic intracranial haemorrhage (tICH) commonly follows falls in elderly people, around half of whom are taking anti-thrombotic (AT) medications pre-injury. ATs are typically stopped acutely, but guidance on safe recommencement is limited.

RESEARCH QUESTION: We surveyed UK neurosurgical consultants to understand variations in AT recommencement practice and inform trial design.

MATERIALS AND METHODS: An online cross-sectional survey was distributed via the Society of British Neurological Surgeons mailing list to assess self-reported consultant practice regarding cessation and recommencement of AT therapy following tICH.

RESULTS: Sixty-two consultant neurosurgeons responded. Following tICH most are very likely or likely to stop AT therapy for AF (92%), stroke prevention (85-90%), or previous MI (78%). There was greater variation when managing those with cardiac stents, with only 59% stopping ATs. Recommencement typically occurred at two weeks post-injury in both conservatively (50%) and surgically (40%) managed patients, with ∼80% of neurosurgeons restarting ATs within four weeks. Most defined early AT resumption to be one-week (72%), while late resumption was more varied at four (39%) and six (31%) weeks. Willingness to randomise was highest in lower-risk cases. More caution was shown to randomising patients with cardiac indications for AT therapy, greater injury severity, and reduced consciousness.

DISCUSSION AND CONCLUSION: These findings highlight the need for better evidence and guidance in this patient group. Based on the survey findings, a trial design targeting patients on AT therapy for AF or secondary VTE prevention, randomised to early (<7 days) versus late (4 weeks) resumption appears a relevant trial question.