Open AccessRestart TICrH: An Adaptive Randomized Trial of Time Intervals to Restart Direct Oral Anticoagulants after Traumatic Intracranial Hemorrhage
Author(s) -
Truman J. Milling,
Steven Warach,
S. Claiborne Johnston,
Byron Gajewski,
Todd W. Costantini,
Michelle Price,
Jo Wick,
Simin Roward,
Dinesh Pal Mudaranthakam,
Adrienne N. Dula,
Benjamin T. King,
Alexander Muddiman,
Gregory Y.H. Lip
Publication year - 2021
Publication title -
journal of neurotrauma
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.653
H-Index - 149
eISSN - 1557-9042
pISSN - 0897-7151
DOI - 10.1089/neu.2020.7535
Subject(s) - medicine , traumatic brain injury , intracranial bleeding , intracerebral hemorrhage , stroke (engine) , randomized controlled trial , intracranial haemorrhage , thrombosis , complication , major bleeding , anesthesia , atrial fibrillation , anticoagulant , surgery , intensive care medicine , cardiology , glasgow coma scale , psychiatry , mechanical engineering , engineering
Anticoagulants prevent thrombosis and death in patients with atrial fibrillation and venous thromboembolism (VTE) but also increase bleeding risk. The benefit/risk ratio favors anticoagulation in most of these patients. However, some will have a bleeding complication, such as the common trip-and-fall brain injury in elderly patients that results in traumatic intracranial hemorrhage. Clinicians must then make the difficult decision about when to restart the anticoagulant. Restarting too early risks making the bleeding worse. Restarting too late risks thrombotic events such as ischemic stroke and VTE, the indications for anticoagulation in the first place. There are more data on restarting patients with spontaneous intracranial hemorrhage, which is very different than traumatic intracranial hemorrhage. Spontaneous intracranial hemorrhage increases the risk of rebleeding because intrinsic vascular changes are widespread and irreversible. In contrast, traumatic cases are caused by a blow to the head, usually an isolated event portending less future risk. Clinicians generally agree that anticoagulation should be restarted but disagree about when. This uncertainty leads to long restart delays causing a large, potentially preventable burden of strokes and VTE, which has been unaddressed because of the absence of high quality evidence. Restart Traumatic Intracranial Hemorrhage (the "r" distinguished intracranial from intracerebral) (TICrH) is a prospective randomized open label blinded end-point response-adaptive clinical trial that will evaluate the impact of delays to restarting direct oral anticoagulation (1, 2, or 4 weeks) on the composite of thrombotic events and bleeding in patients presenting after traumatic intracranial hemorrhage.