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Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury : An Intersociety Consensus Document

Iaccarino, Corrado ; Carretta, Alessandro ; Demetriades, Andreas K. ; Di Minno, Giovanni ; Giussani, Carlo ; Marcucci, Rossella ; Marklund, Niklas LU orcid ; Mastrojanni, Gianmattia ; Pompucci, Angelo and Stefini, Roberto , et al. (2023) In Neurocritical Care
Abstract

Background: All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome. Methods: Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia,... (More)

Background: All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome. Methods: Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation. Results: The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions. Conclusions: The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.

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type
Contribution to journal
publication status
epub
subject
keywords
Anticoagulant, Antiplatelet, Consensus, DOAC, Hemorrhage progression, Reversal strategy, Thrombotic risk, Traumatic brain injury
in
Neurocritical Care
publisher
Humana Press
external identifiers
  • pmid:37029314
  • scopus:85151977915
ISSN
1541-6933
DOI
10.1007/s12028-023-01715-3
language
English
LU publication?
yes
id
f80f3fdc-2968-43e7-8d5b-b9d3dac1defb
date added to LUP
2023-07-19 14:34:55
date last changed
2024-04-19 23:43:13
@article{f80f3fdc-2968-43e7-8d5b-b9d3dac1defb,
  abstract     = {{<p>Background: All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome. Methods: Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation. Results: The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions. Conclusions: The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.</p>}},
  author       = {{Iaccarino, Corrado and Carretta, Alessandro and Demetriades, Andreas K. and Di Minno, Giovanni and Giussani, Carlo and Marcucci, Rossella and Marklund, Niklas and Mastrojanni, Gianmattia and Pompucci, Angelo and Stefini, Roberto and Zona, Gianluigi and Cividini, Andrea and Petrella, Gianpaolo and Coluccio, Valeria and Marietta, Marco}},
  issn         = {{1541-6933}},
  keywords     = {{Anticoagulant; Antiplatelet; Consensus; DOAC; Hemorrhage progression; Reversal strategy; Thrombotic risk; Traumatic brain injury}},
  language     = {{eng}},
  publisher    = {{Humana Press}},
  series       = {{Neurocritical Care}},
  title        = {{Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury : An Intersociety Consensus Document}},
  url          = {{http://dx.doi.org/10.1007/s12028-023-01715-3}},
  doi          = {{10.1007/s12028-023-01715-3}},
  year         = {{2023}},
}