Evidenced based guidelines for restarting warfarin after traumatic brain bleed?

[jdh71]

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I'm banging my head against a wall trying to find information on this topic . . . is it even out there?

Let say, hypothetically speaking, you have an 80 y/o pt, who six months ago fell and had a subarachnoid hemorrhage, who obviously would have been taken off of their coumadin. If her medical history is complicated by chronic afib where one would want the patient on oral anticoagulation therapy, where could a clinician go to find indications of how long, if at all, to wait before restarting the patient's coumadin?

 

[typhoonegator]

I recall looking into this when I was a junior. To my knowledge, there isn't any Class I data regarding when it is safe to reinitiate full anticoagulation after hemorrhage, or even when to start anticoagulation after a large hemispheric or posterior circulation stroke. There are a few case series from Japan looking at P-fossa strokes and anticoagulation, but nothing one could really call "evidence-based".

At my institution, which is very pro-anticoagulation, we would typically restart coumadin in your patient after 4 weeks or so, depending on the severity of the traumatic ICH. We usually wait 2-4 weeks for hemispheric strokes, and 4-6 weeks for large cerebellar strokes (although even the classical teaching that cerebellar strokes are more likely to hemorrhagically convert has not been rigorously studied). However, I've heparinized and hypertensed patients concurrently with fresh stents and big mismatch (big PCA stroke, partially-occlusive basilar clot, active MI) , so it all really depends on your risk-benefit ratio. If you asked 10 stroke neurologists, you'd probably get 6 different answers.

 

[jdh71]

I recall looking into this when I was a junior. To my knowledge, there isn't any Class I data regarding when it is safe to reinitiate full anticoagulation after hemorrhage, or even when to start anticoagulation after a large hemispheric or posterior circulation stroke. There are a few case series from Japan looking at P-fossa strokes and anticoagulation, but nothing one could really call "evidence-based".

At my institution, which is very pro-anticoagulation, we would typically restart coumadin in your patient after 4 weeks or so, depending on the severity of the traumatic ICH. We usually wait 2-4 weeks for hemispheric strokes, and 4-6 weeks for large cerebellar strokes (although even the classical teaching that cerebellar strokes are more likely to hemorrhagically convert has not been rigorously studied). However, I've heparinized and hypertensed patients concurrently with fresh stents and big mismatch (big PCA stroke, partially-occlusive basilar clot, active MI) , so it all really depends on your risk-benefit ratio. If you asked 10 stroke neurologists, you'd probably get 6 different answers.

That's what I was afraid of 😀. Especially after looking for good information - it is surprising there is not more EBM on this topic, considering . . .

Thanks for the reply