Anticoagulation Holiday: Resumption of Direct Oral Anticoagulants for Atrial Fibrillation in Patients with Index Traumatic Intracranial Hemorrhage

Yohannes Ghenbot; John D Arena; Susanna Howard; Connor Wathen; Monisha A Kumar; James M Schuster

doi:10.1016/j.wnsx.2022.100148

Anticoagulation Holiday: Resumption of Direct Oral Anticoagulants for Atrial Fibrillation in Patients with Index Traumatic Intracranial Hemorrhage

World Neurosurg X. 2022 Oct 12:17:100148. doi: 10.1016/j.wnsx.2022.100148. eCollection 2023 Jan.

Authors

Yohannes Ghenbot¹, John D Arena¹, Susanna Howard¹, Connor Wathen¹, Monisha A Kumar², James M Schuster¹

Affiliations

¹ Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
² Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Abstract

Background: The optimal time to restart direct oral anticoagulants (DOACs) for nonvalvular atrial fibrillation (NVAF) after traumatic intracranial hemorrhage (tICH) is unknown. Physicians must weigh the risk of recurrent hemorrhage against ischemic stroke. We investigated rates of stroke while holding anticoagulation, hemorrhage after anticoagulation resumption, and factors associated with the decision to restart anticoagulation.

Methods: Patients presenting to our level I trauma center for tICH while on a DOAC for NVAF were retrospectively reviewed over 2 years. Age, sex, DOAC use, antiplatelet use, congestive heart failure, hypertension, age, diabetes, previous stroke, vascular disease, sex score for stroke risk in NVAF, injury mechanism, bleeding pattern, Injury Severity Score, use of a reversal agent, Glasgow Coma Scale at 24 hours, hemorrhage expansion, neurosurgical intervention, Morse Fall Risk, DOAC restart date, rebleed events, and ischemic stroke were recorded to study rates of recurrent hemorrhage and stroke, and factors that influenced the decision to restart anticoagulation.

Results: Twenty-eight patients sustained tICH while on a DOAC. Fall was the most common mechanism (89.3%), and subdural hematoma was the predominant bleeding pattern (60.7%). Of the 25 surviving patients, 16 patients (64%) restarted a DOAC a median 29.5 days after tICH. One patient had recurrent hemorrhage after resuming anticoagulation. One patient had an embolic stroke after 118 days off anticoagulation. Age >80, Injury Severity Score ≥16, and expansion of tICH influenced the decision to indefinitely hold anticoagulation.

Conclusion: The low stroke rate observed in this study suggests that holding DOACs for NVAF for 1 month is sufficient to reduce the risk of stroke after tICH. Additional data are required to determine optimal restart timing.

Keywords: Atrial fibrillation; CI, Confidence interval; DOAC, Direct oral anticoagulant; DVT, Deep vein thrombosis; Direct oral anticoagulant; ICH, Intracranial hemorrhage; ISS, Injury Severity Score; NVAF, Nonvalvular atrial fibrillation; PE, Pulmonary embolism; RCTs, Randomized control trials; SDH, Subdural hematoma; TBI, Traumatic brain injury; Traumatic intracranial hemorrhage; sICH, Spontaneous intracerebral hemorrhage; tICH, Traumatic ICH.