A systematic review of the timing of therapeutic anticoagulation in adult patients with acute traumatic brain injury: narrative synthesis of observational studies.

Traumatic brain injury (TBI) presents complex management scenarios, particularly in patients requiring anticoagulation for concurrent conditions such as venous thromboembolism (VTE) or atrial fibrillation (AF). A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library databases was conducted to identify relevant studies. Inclusion criteria encompassed studies assessing the effects of anticoagulation therapy on outcomes such as re-hemorrhage, hematoma expansion, thrombotic events, and hemorrhagic events in TBI patients with subdural hematomas (SDH). This systematic review critically addresses two key questions: the optimal timing for initiating anticoagulation therapy and the differential impact of this timing based on the type of intracranial bleed, with a specific focus on subdural hematomas (SDH) compared to other types. Initially screening 508 articles, 7 studies met inclusion criteria, which varied in design and quality, precluding meta-analysis. The review highlights a significant knowledge gap, underscoring the lack of consensus on when to initiate anticoagulation therapy in TBI patients, exacerbated by the need for anticoagulation in the presence of VTE or AF. Early anticoagulation, particularly in patients with SDH, may elevate the risk of re-hemorrhage, posing a clinical dilemma. Evidence on whether the type of intracranial hemorrhage influences outcomes with early anticoagulation remains inconclusive, indicating a need for further research to tailor management strategies effectively. This review underscores the scarcity of high-quality evidence regarding anticoagulation therapy in TBI patients with concurrent conditions, emphasizing the necessity for well-designed prospective studies to elucidate optimal management strategies for this complex patient population.