Traumatic Brain Bleeds: Optimizing the Duration of Anticoagulant and Antiplatelet Therapy

Traumatic brain injuries affect an estimated 69 million individuals worldwide each year. Direct head trauma can lead to traumatic brain bleeds, which carry life-threatening consequences if not promptly addressed. While the current body of research suggests utilizing antithrombotic therapy for treatment, the optimal duration of such treatment remains a subject of debate in neurosurgery. This paper critically examines recommendations for the ideal timing of antiplatelet and anticoagulant therapy in conditions such as subarachnoid hemorrhage, subdural hematoma, skull fractures, cerebral contusions, and diffuse axonal injury. Additionally, it explores the role of these medications in the context of prosthetic valves and stents and assesses their impact on bleeding time and platelet aggregation. The review underscores potential directions for future research in this area, emphasizing the limitations inherent in the current body of literature. While reinitiating appropriate AAT after an interval of cessation to mitigate the risks of ICH is the standard of care in the context of bleeds in TBI, clinicians differ on the timeline and modality of treatment. Various studies demonstrate that reinitiating AAT decreases the long-term risks of thrombotic events and ischemic stroke, but this benefit must be balanced with the risk of developing ICH if AAT is reinitiated too quickly. The timeline for AAT resumption should be based on interdisciplinary risk stratification that takes into consideration patient risk factors and comorbidities that may predispose them to the thromboembolic complications of prolonged AAT cessation.