Direct oral anticoagulant resumption patterns after traumatic subdural hemorrhage in atrial fibrillation: A multicenter cohort study.

INTRODUCTION

Direct oral anticoagulant (DOAC) resumption guidelines after traumatic subdural hemorrhage (tSDH) remain unclear, given the competing risks of worsening hemorrhage and thromboembolic events. This study characterizes real-world DOAC prescription patterns after tSDH in patients with atrial fibrillation (AF) and evaluates outcomes comparing early and late prescription renewal.

METHODS

Using the TriNetX federated research database, we identified adult patients with incident tSDH, a preceding AF diagnosis, and a DOAC prescription within 3 months before injury (2014-2025). Renewal rates and all-cause mortality were tracked at 1, 2, 4, 8, and 12 weeks post-injury. Patients were stratified into early (≤4 weeks) and late (>4 weeks) renewal cohorts and compared following propensity score matching for 1-year rates of cerebral infarction, nontraumatic intracerebral hemorrhage (ICH), gastrointestinal (GI) bleeding, and all-cause mortality

RESULTS

Among 4328 patients (mean age 78.2 years; 61% male), apixaban was the most prescribed pre-injury DOAC (76.7%). Renewal reached 17% at 1 week and 40% by 12 weeks; cumulative mortality was 18% by 12 weeks. After propensity score matching (750 patients per cohort), early renewal was not associated with significantly different rates of cerebral infarction, nontraumatic ICH, or GI bleeding. However, all-cause mortality was significantly higher in the early-renewal cohort (HR [95% CI]: 3.06 [2.33-4.01])

CONCLUSIONS

Early DOAC prescription renewal was associated with markedly higher all-cause mortality without a significant reduction in thromboembolic events. These findings may reflect residual confounding by AF severity, but underscore the need for prospective, injury-specific research to guide anticoagulation decision-making after tSDH.