Abstract：
BACKGROUND: All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome.
METHODS: Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation.
RESULTS: The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions.
CONCLUSIONS: The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.
METHODS: Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation.
RESULTS: The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions.
CONCLUSIONS: The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.
摘要：
背景：所有关于创伤性脑损伤（TBI）患者抗血栓治疗（ATs）管理的现有建议主要基于专家意见，因为现有的循证医学缺乏力量。目前,这些患者的AT的戒断和恢复是经验性的，变化很大，并基于主治医师的个人评估。主要困难是平衡血栓和出血风险以改善患者预后。
方法：在意大利神经外科学会神经创伤学部的认可下，意大利止血和血栓研究学会，意大利麻醉学会,镇痛,复苏,和重症监护,和欧洲神经外科协会，由临床医生组成的工作组(WG)完成了两轮问卷，使用Delphi方法，在多学科的环境中。血栓和出血风险表，高风险和低风险的二分法，是在问卷管理之前建立的。在这张桌子上,风险是通过匹配不同的孤立性TBI(iTBI)方案来计算的，例如急性和慢性硬膜下血肿，硬膜外血肿,脑挫伤（脑出血），以及在积极AT治疗下的患者的外伤性蛛网膜下腔出血。注册的适应症可以包括AT初级预防，心脏瓣膜假体，血管支架,静脉血栓栓塞,和心房颤动。
结果：工作组总共提出了28项陈述，涵盖了关于停用抗血小板的最常见的临床方案，维生素K拮抗剂，和直接口服抗凝剂的患者谁经历了钝性iTBI。工作组对七项建议干预措施的适当性等级进行了投票。总的来说,小组就28个问题中的20个(71%)达成协议，将28人中的11人(39%)视为适当的干预措施，将28人中的9人(32%)视为不适当的干预措施。28个问题中的8个(28%)，干预的适当性被评为不确定。
结论：血栓形成和/或出血风险评分系统的初步建立可以为评估患有iTBI的AT患者的有效管理提供重要的理论依据。可以将列出的建议实施到本地协议中，以实现更均匀的策略。需要开发使用大型患者队列的验证。这是更新iTBI患者AT管理项目的第一部分。
方法：在意大利神经外科学会神经创伤学部的认可下，意大利止血和血栓研究学会，意大利麻醉学会,镇痛,复苏,和重症监护,和欧洲神经外科协会，由临床医生组成的工作组(WG)完成了两轮问卷，使用Delphi方法，在多学科的环境中。血栓和出血风险表，高风险和低风险的二分法，是在问卷管理之前建立的。在这张桌子上,风险是通过匹配不同的孤立性TBI(iTBI)方案来计算的，例如急性和慢性硬膜下血肿，硬膜外血肿,脑挫伤（脑出血），以及在积极AT治疗下的患者的外伤性蛛网膜下腔出血。注册的适应症可以包括AT初级预防，心脏瓣膜假体，血管支架,静脉血栓栓塞,和心房颤动。
结果：工作组总共提出了28项陈述，涵盖了关于停用抗血小板的最常见的临床方案，维生素K拮抗剂，和直接口服抗凝剂的患者谁经历了钝性iTBI。工作组对七项建议干预措施的适当性等级进行了投票。总的来说,小组就28个问题中的20个(71%)达成协议，将28人中的11人(39%)视为适当的干预措施，将28人中的9人(32%)视为不适当的干预措施。28个问题中的8个(28%)，干预的适当性被评为不确定。
结论：血栓形成和/或出血风险评分系统的初步建立可以为评估患有iTBI的AT患者的有效管理提供重要的理论依据。可以将列出的建议实施到本地协议中，以实现更均匀的策略。需要开发使用大型患者队列的验证。这是更新iTBI患者AT管理项目的第一部分。
