Can apixaban be restarted 2 weeks after a bleeding event with a stable and resolving subdural hemorrhage on repeat CT scan?

Restarting Apixaban After Subdural Hemorrhage

Apixaban should not be restarted at 2 weeks after a subdural hemorrhage, even with stable and resolving bleed on repeat CT scan. The recommended waiting period is 3-4 weeks after the bleeding has stabilized. 1

Timing of Anticoagulation Restart

The timing of anticoagulation restart after intracranial hemorrhage requires careful consideration of both bleeding and thrombotic risks:

• Standard recommendation: Anticoagulants should be discontinued during the acute period for at least 1-2 weeks in patients with subdural hemorrhage, with safe restart typically at 3-4 weeks after bleeding has stabilized 1

• American Heart Association guidance: For patients who develop subdural hemorrhage, it is reasonable to discontinue all anticoagulants and antiplatelets during the acute period for at least 1-2 weeks 2

• Evidence from clinical practice: The median restart time for anticoagulation therapy after traumatic subdural hematoma is approximately 1 month after trauma 3

Risk Assessment for Restarting Anticoagulation

When considering restarting apixaban at 2 weeks post-bleed:

• Bleeding risk: Even with a stable and resolving bleed on CT, restarting too early (at 2 weeks) increases the risk of hematoma expansion or recurrent bleeding

• Thrombotic risk: Delaying anticoagulation increases risk of thrombotic events, particularly in patients with atrial fibrillation (10.1% thrombosis/thromboembolism rate vs. 1.0% in controls) 3

• Current evidence: An ongoing clinical trial (Restart TICrH) is specifically investigating optimal timing (1,2, or 4 weeks) for restarting direct oral anticoagulants after traumatic intracranial hemorrhage, indicating that the optimal timing remains uncertain 4

Monitoring and Follow-up

If anticoagulation must be restarted:

• Serial imaging: Obtain follow-up CT scan before restarting anticoagulation and 2-4 weeks after restart to monitor for recurrent bleeding 1

• Clinical monitoring: Close observation for signs of neurological deterioration is essential, particularly in the first 2-4 weeks after restarting therapy 1

• Medication considerations: When restarting, consider using a direct oral anticoagulant like apixaban over vitamin K antagonists due to potentially lower risk of intracranial hemorrhage 1

Practical Approach

1. Current timing (2 weeks): Too early to restart apixaban based on current guidelines and evidence

2. Recommended timing: Wait until 3-4 weeks after the bleeding has stabilized before restarting apixaban 1

3. Interim management: Consider mechanical thromboprophylaxis with intermittent pneumatic compression during the waiting period 1

4. Patient education: Provide clear instructions about warning signs requiring immediate medical attention (new-onset severe headache, confusion, decreased level of consciousness) 1

Common Pitfalls to Avoid

• Restarting too early: Even with a stable CT scan, restarting at 2 weeks increases risk of recurrent bleeding

• Delaying too long: Extended delays beyond 4 weeks may unnecessarily increase thrombotic risk

• Inadequate follow-up: Failure to obtain follow-up imaging after restarting anticoagulation can miss early signs of recurrent bleeding

• Overlooking patient-specific factors: Age, comorbidities, indication for anticoagulation, and size/location of the original bleed all influence the optimal restart timing

In conclusion, despite a stable and resolving bleed on repeat CT scan, restarting apixaban at 2 weeks after a subdural hemorrhage is not recommended. The optimal approach is to wait until 3-4 weeks after bleeding has stabilized before reinitiating anticoagulation.