Recommencement of anti-thrombotics following traumatic intracranial haemorrhage; a preliminary survey of UK consultant neurosurgeons informing the RESTART-tICrH trial design.

INTRODUCTION Traumatic intracranial haemorrhage (tICH) commonly follows falls in elderly people, around half of whom are taking anti-thrombotic (AT) medications pre-injury. ATs are typically stopped acutely, but guidance on safe recommencement is limited. RESEARCH QUESTION We surveyed UK neurosurgical consultants to understand variations in AT recommencement practice and inform trial design. MATERIALS AND METHODS An online cross-sectional survey was distributed via the Society of British Neurological Surgeons mailing list to assess self-reported consultant practice regarding cessation and recommencement of AT therapy following tICH. RESULTS Sixty-two consultant neurosurgeons responded. Following tICH most are very likely or likely to stop AT therapy for AF (92%), stroke prevention (85-90%), or previous MI (78%). There was greater variation when managing those with cardiac stents, with only 59% stopping ATs. Recommencement typically occurred at two weeks post-injury in both conservatively (50%) and surgically (40%) managed patients, with ∼80% of neurosurgeons restarting ATs within four weeks. Most defined early AT resumption to be one-week (72%), while late resumption was more varied at four (39%) and six (31%) weeks. Willingness to randomise was highest in lower-risk cases. More caution was shown to randomising patients with cardiac indications for AT therapy, greater injury severity, and reduced consciousness. DISCUSSION AND CONCLUSION These findings highlight the need for better evidence and guidance in this patient group. Based on the survey findings, a trial design targeting patients on AT therapy for AF or secondary VTE prevention, randomised to early (<7 days) versus late (4 weeks) resumption appears a relevant trial question.