Main Article Content

Ade Ahmad Endang Ranu Khrisna
Shaleh Hafid


Oral anticoagulant and antiplatelet are often prescribed in clinical practice. These drugs are mainly consumed by geriatric patients to prevent or treat cerebrovascular, systemic embolism, or heart condition.  Managing anticoagulated TBI patients is a challenging task for surgeons. This study aims to review available literatures regarding anticoagulated TBI patients and to suggest a treatment algorithm for such cases. Based on several retrospective and prospective studies, it might be wasteful to do a routine follow-up CT scan on anticoagulated TBI patients. The risk of new lesion development or presenting lesion progression seems to be especially low among patients with negative initial CT scan. We suggest to reserve repeat CT scan for patients with evident neurological deterioration. Tighter observation for anticoagulated patients with positive initial CT scan might be useful. Anticoagulation reversal is recommended by the American College of Cardiology, but some studies reported that reversal should be directed by INR. Acute antiplatelet cessation is still controversial for aspirin, but it is advised for clopidogrel. Preoperative management of both anticoagulant and antiplatelet should take into account the bleeding risk of the surgical procedure. Blind cessation and reversal of anticoagulant and/or antiplatelet might delay the timing of surgery and thus would better be avoided


Download data is not yet available.

Article Details

How to Cite
Apriawan, T., Kartosen, A. A., Ishlahy, A. Z. S., Broto, E. P., Herjuna, H. R., Permana, K. R., Meizikri, R., Drehem, S., & Bajamal, A. H. (2020). Management of Traumatic Intracranial Hemorrhage on Anticoagulant Regiment: A Literature Review. International Islamic Medical Journal, 1(2), 74–88.
oral anticoagulant, antiplatelet, TBI, intracranial hemorrhage


Hutchinson, P. J. et al. Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury: Consensus statement. Acta Neurochirurgica 161, 1261–1274 (2019).

Silver, J. & Ziejewski, M. North American Brain Injury Society. J. Head Trauma Rehabil. 33, E67–E118 (2018).

Scotti, P. et al. Antithrombotic agents and traumatic brain injury in the elderly population: hemorrhage patterns and outcomes. J. Neurosurg. 1–10 (2019). doi:10.3171/2019.4.jns19252

Andreotti, F. et al. Antithrombotic therapy in the elderly: expert position paper of the European Society of Cardiology Working Group on Thrombosis. Eur. Heart J. 36, 3238–3249 (2015).

Prexl, O. et al. The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old. Scand. J. Trauma. Resusc. Emerg. Med. 1–7 (2018).

Cipriano, A. et al. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury : significant differences between direct oral anticoagulants and vitamin K antagonists European Federation of Neurological Societies. Intern. Emerg. Med. (2018). doi:10.1007/s11739-018-1806-1

Mina, A. A. et al. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J. Trauma 53, 668–672 (2002).

Patel, R. B. & Tassiopoulos, A. K. Anticoagulants and Surgery: So Many Agents, So Many Taking Them. Adv. Surg. 53, 235–251 (2019).

Palaiodimos, L. et al. Reversal of Novel Anticoagulants in Emergent Surgery and Trauma: A Comprehensive Review and Proposed Management Algorithm. Curr. Pharm. Des. 24, 4540–4553 (2018).

Barnes, G. D., Lucas, E., Alexander, G. C. & Goldberger, Z. D. National trends in ambulatory oral anticoagulant use. Am. J. Med. 128, 1300-1305.e2 (2015).

Barnes, G. D., Ageno, W., Ansell, J. & Kaatz, S. Recommendation on the nomenclature for oral anticoagulants: Communication from the SSC of the ISTH. J. Thromb. Haemost. 13, 1154–1156 (2015).

Baglin, T. et al. Measuring oral direct inhibitors of thrombin and factor Xa: A recommendation from the Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. J. Thromb. Haemost. 11, 756–760 (2013).

Kearon, C. et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 149, 315–352 (2016).

Sørensen, R. et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet 374, 1967–1974 (2009).

Hart, R., Boop, B. & Anderson, D. Oral Anticoagulants and Intracranial Hemorrhage. Facts and Hypotheses - PubMed. Stroke 26, 1471–7 (1995).

Albers, G. W., Sherman, D. G., Gress, D. R., Paulseth, J. E. & Petersen, P. Stroke prevention in nonvalvular atrial fibrillation: A review of prospective randomized trials. Ann. Neurol. 30, 511–518 (1991).

Wang, Y. & Bajorek, B. New oral anticoagulants in practice: Pharmacological and practical considerations. American Journal of Cardiovascular Drugs 14, 175–189 (2014).

Ashrafi, F., Rezaie, N. & Mousavi, S. New indications for dabigatran: A suggestion from a drug use evaluation study. J. Res. Pharm. Pract. 6, 211 (2017).

Connolly, S. J. et al. Dabigatran versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 361, 1139–1151 (2009).

Patel, M. R. et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N. Engl. J. Med. 365, 883–891 (2011).

Granger, C. B. et al. Apixaban versus warfarin in patients with atrial fibrillation. N. Engl. J. Med. 365, 981–992 (2011).

Giugliano, R. P. et al. Edoxaban versus Warfarin in Patients with Atrial Fibrillation. N. Engl. J. Med. 369, 2093–2104 (2013).

Alikhan, R., Bedenis, R. & Cohen, A. T. Heparin for the prevention of venous thromboembolism in acutely ill medical patients (excluding stroke and myocardial infarction). Cochrane Database of Systematic Reviews 2014, (2014).

Barrera, L. M. et al. Thromboprophylaxis for trauma patients. Cochrane Database of Systematic Reviews 2013, (2013).

Kahn, S. R. et al. Prevention of VTE in nonsurgical patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 141, e195S-e226S (2012).

Hirsh, J., Anand, S. S., Halperin, J. L. & Fuster, V. Mechanism of Action and Pharmacology of Unfractionated Heparin. Arterioscler. Thromb. Vasc. Biol. 21, 1094–1096 (2001).

Ibanez, B. et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur. Heart J. 39, 119–177 (2018).

Roffi, M. et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur. Heart J. 37, 267–315 (2015).

Rupprecht, H. J. & Blank, R. Clinical pharmacology of direct and indirect factor xa inhibitors. Drugs 70, 2153–2170 (2010).

Yusuf, S. et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N. Engl. J. Med. 354, 1464–1476 (2006).

Bauer, K. A., Eriksson, B. I., Lassen, M. R. & Turpie, A. G. G. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N. Engl. J. Med. 345, 1305–1310 (2001).

McMillian, W. D. & Rogers, F. B. Management of prehospital antiplatelet and anticoagulant therapy in traumatic head injury: A review. J. Trauma - Inj. Infect. Crit. Care 66, 942–950 (2009).

Nishijima, D. K. et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann. Emerg. Med. 59, 460-468.e7 (2012).

Moustafa, F. et al. Predictive factors of intracranial bleeding in head trauma patients receiving antiplatelet therapy admitted to an emergency department. Scand. J. Trauma. Resusc. Emerg. Med. 26, (2018).

Jentzsch, T. et al. Is rivaroxaban associated with higher morbidity and mortality in patients with traumatic head injuries? A retrospective cohort study comparing rivaroxaban, no anticoagulation, and phenprocoumon. Clin. Neurol. Neurosurg. 169, 116–120 (2018).

Dunham, C. M. et al. Traumatic Intracranial Hemorrhage Correlates with Preinjury Brain Atrophy, but Not with Antithrombotic Agent Use: A Retrospective Study. PLoS One 9, (2014).

Riccardi, A. et al. Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs). Am. J. Emerg. Med. 35, 1317–1319 (2017).

Nishijima, D. K. et al. Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding “Anticoagulation or Antiplatelet Medication Use” as a Criterion. Ann. Emerg. Med. 70, 127-138.e6 (2017).

Inamasu, J. et al. Influence of age and anti-platelet/anti-coagulant use on the outcome of elderly patients with fall-related traumatic intracranial hemorrhage. Neurol. Med. Chir. (Tokyo). 50, 1051–1055 (2010).

Nishijima, D. K., Shahlaie, K., Sarkar, K., Rudisill, N. & Holmes, J. F. Risk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use. Am. J. Emerg. Med. 31, 1244–1247 (2013).

Powers, A. Y. et al. Predicting mortality in traumatic intracranial hemorrhage. J Neurosurg 132, 552–559 (2020).

Won, S. Y. et al. Acute subdural hematoma in patients on oral anticoagulant therapy: Management and outcome. Neurosurg. Focus 43, 1–12 (2017).

Chenoweth, J. A., Johnson, M. A., Sutter, M. E., Nishijima, D. K. & Holmes, J. F. Western Journal of Emergency Medicine : Integrating Emergency Care with Population Health Prevalence of Intracranial Hemorrhage after Blunt Head Trauma in Patients on Pre-injury Dabigatran. West. J. Emerg. Med. 18, (2017)

Rendell, S. & Batchelor, J. S. An analysis of predictive markers for intracranial haemorrhage in warfarinised head injury patients. Emerg. Med. J. 30, 28–31 (2013).

Mina, A. A., Bair, H. A., Howells, G. A. & Bendick, P. J. Complications of preinjury warfarin use in the trauma patient. J. Trauma 52, 842–847 (2003).

Brewer, E. S. et al. Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J. Trauma 70, E1–E5 (2011).

Siracuse, J. J. et al. Antiplatelet agents, warfarin, and epidemic intracranial hemorrhage. Surgery 148, 724–730 (2010).

Fabbri, A., Servadei, F., Marchesini, G., Stein, S. C. & Vandelli, A. Predicting intracranial lesions by antiplatelet agents in subjects with mild head injury. J. Neurol. Neurosurg. Psychiatry 81, 1275–1279 (2010).

Flibotte, J. J., Hagan, N., O’Donnell, J., Greenberg, S. M. & Rosand, J. Warfarin, hematoma expansion, and outcome of intracerebral hemorrhage. Neurology 63, 1059–1064 (2004).

Ivascu, F. A. et al. Predictors of mortality in trauma patients with intracranial hemorrhage on preinjury aspirin or clopidogrel. J. Trauma - Inj. Infect. Crit. Care 65, 785–788 (2008).

Huang, J. L. et al. Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin. Eur. J. Trauma Emerg. Surg. 45, 481–487 (2019).

Menditto, V. G., Lucci, M., Polonara, S., Pomponio, G. & Gabrielli, A. Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol. Ann. Emerg. Med. 59, 451–455 (2012).

Scantling, D. et al. The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy. Eur. J. Trauma Emerg. Surg. 43, 741–746 (2017).

Joseph, B. et al. Low-dose aspirin therapy is not a reason for repeating head computed tomographic scans in traumatic brain injury: A prospective study. J. Surg. Res. 186, 287–291 (2014).

Joseph, B. et al. Clinical outcomes in traumatic brain injury patients on preinjury clopidogrel: A prospective analysis. J. Trauma Acute Care Surg. 76, 817–820 (2014).

Zeeshan, M. et al. The novel oral anticoagulants (NOACs) have worse outcomes compared with warfarin in patients with intracranial hemorrhage after TBI. in Journal of Trauma and Acute Care Surgery 85, 915–920 (Lippincott Williams and Wilkins, 2018).

Parra, M. W. et al. Dabigatran bleed risk with closed head injuries: Are we prepared? J. Neurosurg. 119, 760–765 (2013).

Feeney, J. M. et al. Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: A TQIP study. J. Trauma Acute Care Surg. 81, 843–848 (2016).

Kaen, A. et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J. Trauma - Inj. Infect. Crit. Care 68, 895–898 (2010).

Barmparas, G. et al. The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: A two-center study. Am. J. Surg. 217, 1051–1054 (2019).

Peck, K. A. et al. Delayed intracranial hemorrhage after blunt trauma: Are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? in Journal of Trauma - Injury, Infection and Critical Care 71, 1600–1604 (J Trauma, 2011).

Beynon, C. et al. Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants. Neurocrit. Care 30, 322–333 (2019).

Nishijima, D. K., Dager, W. E., Schrot, R. J. & Holmes, J. F. The efficacy of factor VIIa in emergency department patients with warfarin use and traumatic intracranial hemorrhage. Acad. Emerg. Med. 17, 244–251 (2010).

Deloughery, E. P., Lenfesty, B. & Deloughery, T. G. The use of recombinant factor VIIa in warfarin patients with traumatic brain injury: A retrospective case-control study. Blood Coagul. Fibrinolysis 24, 317–320 (2013).

Oyama, H. et al. Acute subdural hematoma in patients with medication associated with risk of hemorrhage. Neurol. Med. Chir. (Tokyo). 51, 825–828 (2011).

Pruitt, P., Van Ornam, J. & Borczuk, P. A Decision Instrument to Identify Isolated Traumatic Subdural Hematomas at Low Risk of Neurological Deterioration, Surgical Intervention or Radiographic Worsening. Acad. Emerg. Med. 24, 1377–1386 (2017).

Tomaselli, G. F. et al. 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J. Am. Coll. Cardiol. 70, 3042–3067 (2017).

Frontera, J. A. et al. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocrit. Care 24, 6–46 (2016).

Keeling, D., Tait, R. C., Watson, H. & British Committee of Standards for Haematology. Peri-operative management of anticoagulation and antiplatelet therapy. British Journal of Haematology 175, 602–613 (2016).

BRIDGE Study Investigators. Bridging Anticoagulation. Circulation 125, (2012).

Siegal, D. et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: Systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 126, 1630–1639 (2012).

Eijgenraam, P., ten Cate, H. & Cate-Hoek, A. ten. Safety and Efficacy of Bridging with Low Molecular Weight Heparins: A Systematic Review and Partial Meta-Analysis. Curr. Pharm. Des. 19, 4014–4023 (2013).

Franko, J., Kish, K. J., O’Connell, B. G., Subramanian, S. & Yuschak, J. V. Advanced age and preinjury warfarin anticoagulation increase the risk of mortality after head trauma. J. Trauma - Inj. Infect. Crit. Care 61, 107–110 (2006).

Holland, L. & Sarode, R. Should plasma be transfused prophylactically before invasive procedures? Current Opinion in Hematology 13, 447–451 (2006).

Holland, L. L. & Brooks, J. P. Toward Rational Fresh Frozen Plasma Transfusion The Effect of Plasma Transfusion on Coagulation Test Results. Am. J. Clin. Pathol. 126, 133–139 (2006).

West, K. W., Adamson, C. & Hoffman, M. Prophylactic Correction of the International Normalized Ratio in Neurosurgery: A Brief Review of a Brief Literature. J Neurosurg 114, 9–18 (2011).

Davis, J. W. et al. Placement of intracranial pressure monitors: Are ‘normal’ coagulation parameters necessary? J. Trauma - Inj. Infect. Crit. Care 57, 1173–1177 (2004).

Andrews, H., Rittenhouse, K., Gross, B. & Rogers, F. B. The Effect of Time to International Normalized Ratio Reversal on Intracranial Hemorrhage Evolution in Patients with Traumatic Brain Injury. J. Trauma Nurs. 24, 381–384 (2017).

Tedy, Dr. Soetomo General Academic Hospital

Ade, Dr. Soetomo General Academic Hospital

Ahmad, Dr. Soetomo General Academic Hospital

Endang, Dr. Soetomo General Academic Hospital

Ranu, Dr. Soetomo General Academic Hospital

Khrisna, Dr. Soetomo General Academic Hospital

Rizki, Dr. Soetomo General Academic Hospital

Shaleh, Dr. Soetomo General Academic Hospital

Hafid, Dr. Soetomo General Academic Hospital