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  • What is the Current Practice of Restarting Oral Anticoagulant in Patients with Subdural Haemorrhage?

    Final Number:

    Fahad A. Alkherayf MD, MSc, CIP, FRCSC; Philip Wells MD, MSc, FRCPC; Charles B. Agbi MD FRCSC; Harrison Westwick BSc

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: Patients with mechanical heart valves (MHV) who present with subdural haemorrhage (SDH) are initially treated by reversing their coagulopathy. However, these patients will ultimately require that their oral anticoagulant (OAC) be restarted. The time at which OAC are restarted is critical. Too early may increase the risk of recurrent bleeding, while withholding anticoagulants increases the patient’s risk of thromboembolic events.

    Methods: We conducted a survey that included North American members of the AANS and International Society of Thrombosis and Haemostasis (ISTH).Our survey also aimed to examine the relationship among physician’s speciality, country of practice, type of practice, average number of cases they managed annually, years of practice, and timing of restarting OAC. Univariate, bivariate and multivariate analysis was done. Analysis was also done to examine if participant responses to OAC restarting time were different for patients with different clinical risk factors. These risk factors included age, presence of surgical intervention, haematoma size, patient`s CHADS2 score, recent PE, recent DVT, MHV type, MHV location and multiplicity. Multivariate analysis and Poisson regression model were conducted to examine the effect of participant characteristics and demographics on the time of restarting OAC. All analyses were performed at the conventional alpha value of 0.05. All analyses were performed using STATA 11, SPSS, R2.15.1 and Microsoft Excel.

    Results: A total of 504 physicians responded to our survey (34.31%). In patients with no risk factors OAC were resumed within: 3 days by 14.5%, 4-5 days by 22%, 6-7 days by 19%, 8-14 days by 20% while the rest of the participants resumed them after 2 weeks. Craniotomy (P 0.001), haematoma size (P 0.001), recent PE (P 0.001) and multiple MHVs (P 0.001) were significant predictors for restarting OAC. Annual numbers of cases managed by participants’ were found to be the only statistically significant (P 0.01) participant`s characteristic which influenced their decision.

    Conclusions: There is a wide variation in the current practice of neurosurgeons when they face the dilemma of managing patients with SDH and MHV.

    Patient Care: This should improve the neurosurgeons knowledge when they are involved in management of SDH associated with OAC by balancing the risk of further bleeding against thromboembolic complications.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of restarting OAC in patients with MHV and SDH) Discuss what should be the ideal time of restarting OAC in patients with MHV, 3) Identify factors which may influence the timing of restarting OAC.

    References: 1. Butany J, Ahluwalia MS, Munroe C, et al. Mechanical heart valve prostheses: Identification and evaluation. Cardiovascular Pathology. 2003;12:1-22. 2. Schoen FJ. Future directions in tissue heart valves: Impact of recent insights from biology and pathology. J Heart Valve Dis. 1999;8:350-358. 3. Starr A, Edwards ML. Mitral replacement: Clinical experience with a ball-valve prosthesis. Ann Surg. 1961;154:726-740. 4. Pibarot P, Dumesnil JG. Prosthetic heart valves: Selection of the optimal prosthesis and long-term management. Circulation. 2009;119:1034-1048. 5. Bonow RO. Carabello BA. Chatterjee K. de Leon AC Jr. Faxon DP. Freed MD. Gaasch WH. Lytle BW. Nishimura RA. O'Gara PT. O'Rourke RA. Otto CM. Shah PM. Shanewise JS. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American college of Cardiology/American heart association task force on practice guidelines (writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). endorsed by the society of cardiovascular anesthesiologists, society for cardiovascular angiography and interventions, and society of thoracic surgeons. J Am Coll Cardiol. 2008;52:e1-142. 6. Akhtar RP, Abid AR, Zafar H, et al. Anticoagulation in patients following prosthetic heart valve replacement. Annals of Thoracic & Cardiovascular Surgery. 2009;15:10-17. 7. Lengyel M. Horstkotte D. Voller H. Mistiaen WP. Working Group Infection, Thrombosis, Embolism and Bleeding of the Society for Heart Valve Disease. Recommendations for the management of prosthetic valve thrombosis. J Heart Valve Dis. 2005;14:567-575. 8. Al-Ahmad AM, Hartnett-Daudelin D, Salem DN. Antithrombotic therapy for prosthetic valves: Routine treatment and special considerations. Curr Cardiol Rep. 2001;3:85-89. 9. Ananthasubramaniam K, Beattie JN, Rosman HS, et al. How safely and for how long can warfarin therapy be withheld in prosthetic heart valve patients hospitalized with a major hemorrhage?. Chest. 2001;119:478-484. 10. Crawley F, Bevan D, Wren D. Management of intracranial bleeding associated with anticoagulation: Balancing the risk of further bleeding against thromboembolism from prosthetic heart valves. Journal of Neurology, Neurosurgery & Psychiatry. 2000;69:396-398. 11. Tiede DJ, Nishimura RA, Gastineau DA, et al. Modern management of prosthetic valve anticoagulation. Mayo Clin Proc. 1998;73:665-680. 12. Bonow RO, Carabello B, de Leon AC, et al. ACC/AHA guidelines for the management of patients with valvular heart disease. executive summary. A report of the American college of Cardiology/American heart association task force on practice guidelines (committee on management of patients with valvular heart disease). J Heart Valve Dis. 1998;7:672-707. 13. Heras M, Fernandez Ortiz A, Gomez Guindal JA, et al. [Practice guidelines of the Spanish society of cardiology. recommendations for the use of antithrombotic treatment in cardiology]. Rev Esp Cardiol. 1999;52:801-820. 14. Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: The task force on the management of valvular heart disease of the European society of cardiology. Eur Heart J. 2007;28:230-268. 15. Gallus AS, Baker RI, Chong BH, et al. Consensus guidelines for warfarin therapy. recommendations from the Australasian society of thrombosis and haemostasis. Med J Aust. 2000;172:600-605. 16. Baglin TP, Keeling DM, Watson HG, et al. Guidelines on oral anticoagulation (warfarin): Third edition--2005 update. Br J Haematol. 2006;132:277-285. 17. Baker RI, Coughlin PB, Gallus AS, et al. Warfarin reversal: Consensus guidelines, on behalf of the Australasian society of thrombosis and haemostasis. Med J Aust. 2004;181:492-497. 18. Broderick J. Connolly S. Feldmann E. Hanley D. Kase C. Krieger D. Mayberg M. Morgenstern L. Ogilvy CS. Vespa P. Zuccarello M. American Heart Association/American Stroke Association Stroke Council. American Heart Association/American Stroke Association High Blood Pressure Research Council. Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: A guideline from the American Heart Association/American stroke association stroke council, high blood pressure research council, and the quality of care and outcomes in research interdisciplinary working group. Circulation. 2007;116:e391-413. 19. Steiner T, Rosand J, Diringer M. Intracerebral hemorrhage associated with oral anticoagulant therapy: Current practices and unresolved questions. Stroke. 2006;37:256-262. 20. Hammermeister K, Sethi GK, Henderson WG, et al. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: Final report of the veterans affairs randomized trial. J Am Coll Cardiol. 2000;36:1152-1158. 21. Cannegieter SC, Rosendaal FR, Wintzen AR, et al. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med. 1995;333:11-17. 22. Mori T, Asano M, Ohtake H, et al. Anticoagulant therapy after prosthetic valve replacement -optimal PT-INR in japanese patients-. Annals of Thoracic & Cardiovascular Surgery. 2002;8:83-87. 23. Hill JD, LaFollette L, Szarnicki RJ, et al. Risk-benefit analysis of warfarin therapy in hancock mitral valve replacement. Journal of Thoracic & Cardiovascular Surgery. 1982;83:718-723. 24. Hart RG, Tonarelli SB, Pearce LA. Avoiding central nervous system bleeding during antithrombotic therapy: Recent data and ideas. Stroke. 2005;36:1588-1593. 25. Jeffree RL, Gordon DH, Sivasubramaniam R, et al. Warfarin related intracranial haemorrhage: A case-controlled study of anticoagulation monitoring prior to spontaneous subdural or intracerebral haemorrhage. Journal of Clinical Neuroscience. 2009;16:882-885. 26. Punthakee X, Doobay J, Anand SS. Oral-anticoagulant-related intracerebral hemorrhage. Thromb Res. 2002;108:31-36. 27. Rosand J, Eckman MH, Knudsen KA, et al. The effect of warfarin and intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. 2004;164:880-884. 28. Hart RG, Boop BS, Anderson DC. Oral anticoagulants and intracranial hemorrhage. facts and hypotheses. Stroke. 1995;26:1471-1477. 29. D'Angelo GJ, Kish GF, Sardesai PG, et al. Clinical assessment of the st. jude medical cardiac prosthesis. A 5-year experience. Am Surg. 1986;52:101-104. 30. Chimowitz MI, Lynn MJ, Howlett-Smith H, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005;352:1305-1316. 31. Hylek EM, Singer DE. Risk factors for intracranial hemorrhage in outpatients taking warfarin. Ann Intern Med. 1994;120:897-902. 32. Flaherty ML, Haverbusch M, Sekar P, et al. Location and outcome of anticoagulant-associated intracerebral hemorrhage. Neurocritical Care. 2006;5:197-201. 33. Wijdicks EF, Schievink WI, Brown RD, et al. The dilemma of discontinuation of anticoagulation therapy for patients with intracranial hemorrhage and mechanical heart valves. Neurosurgery. 1998;42:769-773. 34. Appelboam R, Thomas EO. Warfarin and intracranial haemorrhage. Blood Rev. 2009;23:1-9. 35. Flibotte JJ, Hagan N, O'Donnell J, et al. Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology. 2004;63:1059-1064. 36. Aguilar MI, Hart RG, Kase CS, et al. Treatment of warfarin-associated intracerebral hemorrhage: Literature review and expert opinion. Mayo Clin Proc. 2007;82:82-92. 37. Bertram M, Bonsanto M, Hacke W, et al. Managing the therapeutic dilemma: Patients with spontaneous intracerebral hemorrhage and urgent need for anticoagulation. J Neurol. 2000;247:209-214. 38. Nakagawa T, Kubota T, Handa Y, et al. Intracranial hemorrhage due to long-term anticoagulant therapy in patients with prosthetic heart valves--four case reports. Neurol Med. 1995;35:156-159. 39. Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. Chest. 2001;119:22S-38S. 40. Nagano N, Tabata H, Hashimoto K. Anticoagulant-related intracerebral hemorrhage in patients with prosthetic heart valves--report of two cases. Neurol Med. 1991;31:743-745. 41. Butler AC, Tait RC. Restarting anticoagulation in prosthetic heart valve patients after intracranial haemorrhage: A 2-year follow-up. Br J Haematol. 1998;103:1064-1066. 42. Phan TG, Koh M, Wijdicks EF. Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk. Arch Neurol. 2000;57:1710-1713. 43. Caird J, Chukwunyerenwa C, Ali Z, et al. Craniotomy with prosthetic heart valves: A clinical dilemma. Br J Neurosurg. 2006;20:40-42. 44. Sharma SN, Iyengar SS, Nandi B. Prosthetic heart valve, antiocoagulants and cerebral hemorrhage. J Assoc Physicians India. 1994;42:581. 45. Babikian VL, Kase CS, Pessin MS, et al. Resumption of anticoagulation after intracranial bleeding in patients with prosthetic heart valves. Stroke. 1988;19:407-408. 46. Coma-Canella I. [Anticoagulation in pregnancy]. Rev Esp Cardiol. 1994;47:50-59. 47. Simonazzi G, Pilu G, Palareti G, et al. Foetal cerebral hemispheric atrophy and porencephaly after intrauterine exposure to maternal warfarin for mechanical prosthetic heart valve. Prenat Diagn. 2008;28:157-159. 48. Raivio KO, Ikonen E, Saarikoski S. Fetal risks due to warfarin therapy during pregnancy. Acta Paediatr Scand. 1977;66:735-739. 49. Javares T, Coto EO, Maiques V, et al. Pregnancy after heart valve replacement. Int J Cardiol. 1984;5:731-743. 50. Cochrane Handbook for Systematic Reviews of Interventions. England: John Wiley & Sons Ltd., 2008. 51. Littell J, Corcoran J, Pillai V. Systematic Reviews and Meta-Analysis. New York: OXFORD University Press, 2008. 52. Yeon JY, Kong DS, Hong SC. Safety of early warfarin resumption following burr hole drainage for warfarin-associated subacute or chronic subdural hemorrhage. J Neurotrauma. 2012;29:1334-1341. 53. Randolph JJ. Online Kappa Calculator. Available at: 54. RefWorks. 2009;1.0. Available from: 55. Salem DN, O'Gara PT, Madias C, et al. Valvular and structural heart disease: American college of chest physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:ate of Pubaton: Jun 2008. 56. O'Donnell M, Hirsh J. Establishing an optimal therapeutic range for coumarins: Filling in the gaps. Arch Intern Med. 2004;164:ate of Pubaton: 22 Mar 2004. 57. Wells G, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available at: 58. Phillips B, Ball C, Sackett D, Straus S, Haynes B, Howick J, Dawes M. Oxford centre for Evidence-based Medicine. Available at: 59. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557-560. 60. SAS Institute Inc. SAS. ;9.1. 61. Guido Schwarzer. Meta-analysis package for R. 2011. 62. Tsai Y-, Lee C-, Hong G-, et al. Long-term experience of anticoagulant therapy in chinese patients with mechanical valves. Journal of Medical Sciences. 2007;27:ate of Pubaton: e 2007. 63. Katsuki T, Saito M, Noda T, et al. [Long-term follow-up in patients receiving anticoagulation therapy: Potency of therapy and complications]. J Cardiol. 1994;24:203-209. 64. Oka K, Kamota T, Satou M, et al. [Subdural hematoma following cardiac surgery]. Kyobu Geka. 2008;61:868-872. 65. Kasahara S, Sakai A, Isomatsa Y, et al. [Subdural hematoma complicated after open heart surgery: A report of two cases with successful treatment]. Kyobu Geka - Japanese Journal of Thoracic Surgery. 1994;47:732-735. 66. Hinata S, Hiekata T, Kamata S, et al. [Subarachnoid hemorrhage following commencement of danazol treatment in a patient well controlled on warfarin anticoagulation]. Kyobu Geka. 1991;44:555-557. 67. Nobuoka W, Konishi M, Asazuma S. A case report of chronic subdural hematoma during long-term anticoagulant drug therapy after mitral valve replacement. Japanese Annals of Thoracic Surgery. 1984;4:ate of Pubaton: 1984. 68. Asai Y, Sugiki K, Abe T, et al. [Surgical experience of subacute subdural hematoma occurring during the anticoagulant therapy]. Rinsho Kyobu Geka. 1984;4:87-91. 69. Lagares A, Dominguez J, Lobato RD, et al. Bilateral posterior fossa subdural haematomas secondary to anticoagulant therapy. Acta Neurochir (Wien). 1998;140:1097-1098. 70. Barbero F, Pengo V, Fasoli G. Fatal cerebral hemorrhage complicating thromboembolic stroke in a patient with prosthetic mitral valve thrombosis treated with thrombolytic therapy. Clinical and Applied Thrombosis/Hemostasis. 1997;3:ate of Pubaton: Ot 1997. 71. Chee CP, Bailey IC, Refsum SE. Spontaneous massive haemorrhage into acoustic neuroma during anticoagulation therapy. Br J Neurosurg. 1987;1:489-493. 72. Fanikos J, Grasso-Correnti N, Shah R, et al. Major bleeding complications in a specialized anticoagulation service. Am J Cardiol. 2005;96:595-598. 73. Ben Ameur Y, Chaabane O, Zairi I, et al. Haemorrhagic serious accident in anti-vitamin K. descriptive study and prognostic. . 74. Atanasov V, Gabrovski S, Velkova S, et al. [Intracranial hemorrhages in patients being treatment with anticoagulants]. Khirurgiia. 1999;54:34-36. 75. Aoyagi S, Hori H, Yoshikawa K, et al. Mid-term results of valve replacement with the ATS valve: A seven-year follow up. J Heart Valve Dis. 2007;16:ate of Pubaton: May 2007.

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