Reinitiation of Anticoagulation After Surgical Evacuation of Subdural Hematomas

Abstract

Background: Chronic subdural hematoma (cSDH) is an increasingly common condition due to the growing use of anticoagulation. Currently, there remains a lack of evidence to guide the optimal timing of anticoagulant reinitiation for stroke prevention in atrial fibrillation after cSDH evacuation. We aimed to better understand the perceived risks of hemorrhagic and embolic complications along with current practice patterns on restarting anticoagulation after surgical evacuation of cSDH.

Methods: We conducted a survey of Canadian neurosurgeons and stroke neurologists using a novel self-administered questionnaire using clinical cases that included questions on clinical experience, practice setting, practice patterns, and perceptions on stroke/bleeding risk with anticoagulation reinitiation after cSDH evacuation. The instrument was evaluated for clinical sensibility by 5 neurosurgeons, neurologists, and intensivists.

Results: The response rate after 4 mailings was 40% for neurosurgeons (55/136) and 21% for stroke neurologists (26/122). Almost all participants would restart anticoagulation for stroke prevention in atrial fibrillation after cSDH evacuation (91.8% in low-risk patients, 98.6% in high-risk patients). Time to reinitiation of anticoagulation varied considerably, particularly for high-risk patients where 36% of participants would restart anticoagulation within 1 week of surgery, 44% between 1 and 4 weeks after surgery, and 19% after 4 weeks postoperatively. The perceived risk of stroke and SDH reaccumulation varied considerably among participants and was dependent on timing of anticoagulation reinitiation.

Conclusions: There is considerable variation in current practice patterns and perceived risks of embolic and hemorrhagic complications with anticoagulation reinitiation after cSDH evacuation. These results demonstrate clinical equipoise that warrant further targeted investigation in large-scale randomized controlled trials.

Keywords: Adult; Cerebral; Clinical neurosciences; Clotting platelets; Hemorrhage; Neurology; Neurosurgery; Stroke.