title: Timing of anticoagulant re-initiation following intracerebral hemorrhage in mechanical heart valves: Survey of neurosurgeons and thrombosis experts.
abstract: BACKGROUND
  While oral anticoagulation (OAC) is universally indicated for patients with mechanical heart valves (MHVs), OAC resumption following anticoagulant-associated intracerebral hemorrhage (ICH) is an area of uncertainty. We sought to determine the practice preferences of North American neurosurgeons and thrombosis experts on optimal timing of OAC re-initiation.
  
  
  METHODS
  A cross-sectional survey was disseminated to North American members of the American Association of Neurological Surgeons and the International Society for Thrombosis and Haemostasis. Demographic factors, as well as a clinical scenario with 14 modifiable clinical risk factors were included in the survey.
  
  
  RESULTS
  504 physicians completed our survey (response rate 34.3%). Majority of participants were affiliated with academic centres, and managed≤10 ICH patients with MHV per year. There was wide distribution in response in optimal timing for OAC resumption following an ICH: 59% and 60% preferred to re-start OAC between 3 and 14 days following the hemorrhagic event (median of 6-7 days). Smaller hemorrhages (<30cm2). CHADS2score ≥2, concomitant venous thromboembolism, mitral valve prosthesis, caged-ball valves and multiple valves prompted earlier OAC resumption.
  
  
  CONCLUSIONS
  Wide variation in the current practice of neurosurgeons and thrombosis specialists exist when they encounter patients with ICH and MHV, though decisions were influenced by patient- and valve-related factors. As our observed variation likely reflects the immense gap in current evidence, prospective randomized trials in this population are therefore urgently needed.
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada. Electronic address: falkherayf@toh.ca.
authors.forename: Fahad
authors.initials: F
authors.lastname: AlKherayf
authors.affiliation: School of Medicine, Queen's University, Kingston, Canada; Division of Hematology, Department of Medicine, Ottawa, Canada.
authors.forename: Yan
authors.initials: Y
authors.lastname: Xu
authors.affiliation: Division of Neurosurgery, Department of Surgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada.
authors.forename: Harrison
authors.initials: H
authors.lastname: Westwick
authors.affiliation: Division of Neurosurgery, Department of Surgery, University of Ottawa, Ottawa, Canada.
authors.forename: Ioana Doina
authors.initials: ID
authors.lastname: Moldovan
authors.affiliation: Division of Hematology, Department of Medicine, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada.
authors.forename: Philip S
authors.initials: PS
authors.lastname: Wells
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D000072096:Cardiologists / Q000706:statistics & numerical data; D002543:Cerebral Hemorrhage / Q000139:chemically induced; D003430:Cross-Sectional Studies; D019538:Health Care Surveys; D006350:Heart Valve Prosthesis; D006801:Humans; D008875:Middle Aged; D000069471:Neurosurgeons / Q000706:statistics & numerical data; D009656:North America; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013997:Time Factors
chemical_list: D000925:Anticoagulants
keywords: Anticoagulant; Intracerebral hemorrhage; Mechanical heart valves; Subdural hematoma; Survey