Primary prevention

Seat belts and helmets should be used when applicable.[45][46]​​ Coagulation profiles should be routinely monitored by physicians prescribing anticoagulants.[34]

Secondary prevention

Physiotherapy, walking aids, and gait training may be used to reduce the chance of subsequent falls and head trauma.

Decisions on long-term use of anticoagulation and antiplatelet agents following recovery from subdural haematoma (SDH) must be personalised, according to the individual patient’s relative risks of bleeding versus thrombosis.[30][59]​ Advice should be sought from haematology and cardiology teams. In most patients the balance is in favour of ongoing anticoagulation but evidence to guide the optimum timing of reinitiation is scarce and there is an urgent need for high-quality trials.[59][199]​​[200]

The American College of Surgeons recommends to restart anticoagulation no later than 14-90 days after traumatic brain injury, depending on patient-specific risk for thrombosis and bleeding.[49]​ Clinical practice varies significantly but most clinicians consider it safe to restart anticoagulation in the majority of patients after a 2-week break, although it may need to be sooner in individuals with a very strong indication for anticoagulation (e.g., a recent venous thromboembolism or a metallic heart valve).​​[30][59]​​[96]​ Safe restart of anticoagulant therapy may also occur significantly sooner, especially if traumatic intracranial bleeding is less significant and/or stable on repeat computed tomographic (CT) imaging.[49][88]

Antiplatelet agents may be restarted as early as 4 days after injury, based on assessment of patient-specific risk for thrombosis and bleeding.[49]​ Risks for acute and delayed intracranial haemorrhage after restarting antiplatelet agents must be weighed against the morbidity of thrombotic complications that can have significant clinical consequences.[49]

It has been suggested that repeat CT scanning may help to inform the risk-benefit decision in patients for whom there is significant doubt.[30]​ A stable intracranial appearance may support reinitiation of anticoagulant or antiplatelet therapy whereas evidence of new acute bleeding may favour delaying this step.[30][201]​​

In one retrospective study, resuming anticoagulation 6 to 8 weeks following haemorrhage reduced mortality, thrombotic events, and haemorrhagic events.[202]​ In another study, resuming anticoagulation less than 2 weeks from haemorrhagic events in patients with mechanical heart valves increased the risk of haemorrhagic events.[203]​ The 2022 American Heart/American Stroke Association guidelines on anticoagulation suggest that the size of haematoma, patient age, and extent of risk for thrombosis should all be considered when reinitiating anticoagulation.[94]​ 

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