Volume 3, Issue 1 (1-2025)                   Neuroscience Updates 2025, 3(1): 36-50 | Back to browse issues page

XML Print

Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:
Mozafari P, Basmajian G, Rahmath D, Kalsahakian A, Hamza Sayed M, Bagheri M H. Redefining Anticoagulation in Neurosurgical Patients with Atrial Fibrillation: A Narrative Review of Risk Mitigation and Personalized Neuroprotection. Neuroscience Updates 2025; 3 (1) :36-50
URL: http://neuroupdates.de/article-1-125-en.html
Redefining Anticoagulation in Neurosurgical Patients with Atrial Fibrillation: A Narrative Review of Risk Mitigation and Personalized Neuroprotection
Parvin Mozafari *1 , Garin Basmajian2 , Daniya Rahmath2 , Alvina Kalsahakian2 , Mohammed Hamza Sayed2 , Mohammad Hassan Bagheri3
1- Faculty of Medicine, University of Georgia, Tbilisi, Georgia
2- Yerevan State Medical University, Yerevan, Armenia
3- Tehran University of Medical Sciences, Tehran, Iran
Abstract:   (77 Views)

Intracerebral hemorrhage (ICH) occurs as a disastrous complication in any surgical patient who is undergoing neurosurgery and especially in those who have atrial fibrillation and are under anticoagulation treatment. There exists a dilemma of risk versus bleeding in the clinical care of such patients. The proposed narrative review will help to establish optimal practices in the management of anticoagulants and neuroprotection in atrial fibrillation patients undergoing neurosurgery. The extensive literature search was carried out in PubMed, and the studies that reported the results of different anticoagulation treatments and their effects on the outcomes of surgery were selected. The data obtained were thematically synthesized to provide the patterns of clinical and pharmacological trends. The discussion identifies the neurological issues experienced by such patients with the focus on the maintenance of neuronal survival and cerebral homeostasis. A proposal of a so-called neuro-safe window to restart anticoagulation is discussed, taking into account the nature of anticoagulants used, cerebral autoregulation, and patient peculiarities. The review recommends an individual approach to anticoagulation, with neuro-specific parameters and methods of monitoring being added to improve neurological outcome. In addition, the opportunities of neuroprotective measures, e.g. facilitating microvascular blood flow and autoregulation, are addressed. To sum up, the anticoagulants management and reduction of the neurological events in the patients undergoing neurosurgery with atrial fibrillation require personalized risk models and future trials.

Keywords: Neurosurgery, Intracranial hemorrhage, Atrial fibrillation, Anticoagulant therapy, Ischemic stroke
     
Type of Study: Review Article | Subject: Neurodegenerative Disease
Received: 2025/05/25 | Accepted: 2025/07/10 | Published: 2025/07/20
References
1. A, Barbato C, Galmozzi F, Camilleri E, Cesari F, Chiti S, et al. Role of biological markers for cerebral bleeding risk stratification in patients with atrial fibrillation on oral anticoagulants for primary or secondary prevention of ischemic stroke (Strat-AF study): study design and methodology. Medicina (Kaunas). 2019;55(10):626. doi:10.3390/medicina55100626. [DOI:10.3390/medicina55100626] [PMID] [PMCID]
2. Shoamanesh A, Klijn CJM, Sheth KN, Veltkamp R, Sandset EC, Cordonnier C, et al. Oral anticoagulation following intracranial haemorrhage in patients with atrial fibrillation. Eur Stroke J. 2025;10(1 Suppl):35-45. doi:10.1177/23969873241296803. [DOI:10.1177/23969873241296803] [PMID] [PMCID]
3. Alghamdi AM, Alkulli OA, Fatani F, Subahi FS, Tayeb AF, Alghamdi A, et al. Management and outcomes of intracranial hemorrhage in atrial fibrillation patients: highlighting practices in Saudi Arabia. World Neurosurg X. 2025;17:100148. doi:10.1016/j.wnsx.2022.100148. [DOI:10.1016/j.wnsx.2022.100148] [PMID] [PMCID]
4. Ghenbot Y, Arena JD, Howard S, Wathen C, Kumar MA, Schuster JM. Anticoagulation holiday: resumption of direct oral anticoagulants for atrial fibrillation in patients with index traumatic intracranial hemorrhage. World Neurosurg X. 2022;17:100148. doi:10.1016/j.wnsx.2022.100148. [DOI:10.1016/j.wnsx.2022.100148] [PMID] [PMCID]
5. Mansouri A, Nassiri F, Scales D, Pirouzmand F. Anticoagulation therapy timing in patients with atrial fibrillation after acute and chronic subdural haematoma (ATTAACH): a pilot randomized controlled trial. BMJ Open. 2024;14(10):e090224. doi:10.1136/bmjopen-2024-090224. [DOI:10.1136/bmjopen-2024-090224] [PMID] [PMCID]
6. Matsushima K, Leichtle SW, Wild J, Young K, Chang G, Demetriades D; EAST ACT-TBI Multicenter Study Group. Anticoagulation therapy in patients with traumatic brain injury: an Eastern Association for the Surgery of Trauma multicenter prospective study. Surgery. 2021;169(2):470-6. doi:10.1016/j.surg.2020.07.040. [DOI:10.1016/j.surg.2020.07.040] [PMID] [PMCID]
7. Zhu T, Wang L, Wang LP, Wan Q. Therapeutic targets of neuroprotection and neurorestoration in ischemic stroke: applications for natural compounds from medicinal herbs. Biomed Pharmacother. 2022;148:112719. doi:10.1016/j.biopha.2022.112719. [DOI:10.1016/j.biopha.2022.112719] [PMID]
8. Douketis JD, Li N, St John M, Nixon J, Moffat K, Shaw J, et al. Perioperative management of direct oral anticoagulants in patients having a high-bleed-risk surgery or neuraxial procedure: the PAUSE-2 pilot randomized trial. J Thromb Haemost. 2025;23(7):2226-34. doi:10.1016/j.jtha.2025.03.003. [DOI:10.1016/j.jtha.2025.03.003] [PMID]
9. Davison MA, Patel AA, Lilly DT, Shost MD, Kashkoush AI, Krishnaney AA, et al. Risk assessment of early therapeutic anticoagulation following cranial surgery: an institutional case series. J Neurosurg. 2024;141(4):1138-46. doi:10.3171/2024.2.JNS24146. [DOI:10.3171/2024.2.JNS24146] [PMID]
10. Zhao B, Yuan Y, Li Z, Chen Y, Gao Y, Yang B, et al. Risk of intracranial hemorrhage in patients using anticoagulant therapy for atrial fibrillation after cerebral microbleeds combined with acute ischemic stroke: a meta-analysis. Front Neurol. 2024;15:1372231. doi:10.3389/fneur.2024.1372231. [DOI:10.3389/fneur.2024.1372231] [PMID] [PMCID]
11. Streb W, Lasek-Bal A, Mitręga K, Kowalczyk J, Podolecki T, Kowalska W, et al. Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure: LAAC-SBI trial. Trials. 2023;24(1):749. doi:10.1186/s13063-023-07766-3. [DOI:10.1186/s13063-023-07766-3] [PMID] [PMCID]
12. Robba C, Bertuetti R, Rasulo F, Bertuccio A, Matta B. Coagulation management in patients undergoing neurosurgical procedures. Curr Opin Anaesthesiol. 2017;30(5):527-33. doi:10.1097/ACO.0000000000000496. [DOI:10.1097/ACO.0000000000000496] [PMID] [PMCID]
13. Kreitzer N, Adeoye O. Intracerebral hemorrhage in anticoagulated patients: evidence-based emergency department management. Emerg Med Pract. 2015;17(12):1-23.
14. Zhou Q, Liu X, Yang X, Huang XH, Wu YZ, Tao YY, et al. Efficacy and safety of anticoagulation in atrial fibrillation patients with intracranial hemorrhage: a systematic review and meta-analysis. Front Pharmacol. 2023;14:1122564. doi:10.3389/fphar.2023.1122564. [DOI:10.3389/fphar.2023.1122564] [PMID] [PMCID]
15. Tommiska P, Knuutinen O, Lönnrot K, Kivisaari R, Raj R. Association between postoperative thromboembolic and hemorrhagic complications and clinical outcomes after surgery for chronic subdural hematoma in patients with anticoagulation therapy for atrial fibrillation. Acta Neurochir (Wien). 2025;167(1):17. doi:10.1007/s00701-024-06417-z. [DOI:10.1007/s00701-024-06417-z] [PMID] [PMCID]
16. Prior A, Fiaschi P, Iaccarino C, Stefini R, Battaglini D, Balestrino A, et al. How do you manage anticoagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH). BMC Neurol. 2021;21:98. doi:10.1186/s12883-021-02135-3. [DOI:10.1186/s12883-021-02126-7] [PMID] [PMCID]
17. Puy L, Forman R, Cordonnier C, Sheth KN. Protecting the brain, from the heart: safely mitigating the consequences of thrombosis in intracerebral hemorrhage survivors with atrial fibrillation. Stroke. 2022;53(7):2152-60. doi:10.1161/STROKEAHA.122.036888. [DOI:10.1161/STROKEAHA.122.036888] [PMID]
18. Mehta VA, Wang TY, Sankey EW, Howell EP, Goodwin CR, Levy JH, et al. Restarting therapeutic anticoagulation after elective craniotomy for patients with chronic atrial fibrillation: a review of the literature. World Neurosurg. 2020;137:130-6. doi:10.1016/j.wneu.2020.01.235. [DOI:10.1016/j.wneu.2020.01.235] [PMID]
19. Roychoudhury R, Ma S, Qian C. Stroke prevention and intracranial hemorrhage risk in atrial fibrillation management: a mini review. Brain Circ. 2023;9(3):148-53. doi:10.4103/bc.bc_22_23. [DOI:10.4103/bc.bc_22_23] [PMID] [PMCID]
20. Foerch C, Lo EH, van Leyen K, Lauer A, Schaefer JH. Intracerebral hemorrhage formation under direct oral anticoagulants: clinical and translational evidence. Stroke. 2019;50(4):891-8. doi:10.1161/STROKEAHA.118.023722. [DOI:10.1161/STROKEAHA.118.023722] [PMID]
21. Koji T, Kubo Y, Matsumoto Y, Akamatsu Y, Chida K, Kashimura H, et al. Intracranial hemorrhage associated with direct oral anticoagulant after clipping for an unruptured cerebral aneurysm: a report of two cases. Surg Neurol Int. 2022;13:104. [DOI:10.25259/SNI_1223_2021] [PMID] [PMCID]
22. Tommasi C, Rossi M, Bianchi A, Conti P. The rate of postoperative hematoma following risk-adapted cessation of oral anticoagulation in patients undergoing endoscopic endonasal surgery for pituitary adenomas. Acta Neurochir (Wien). 2024;166:496. [DOI:10.1007/s00701-024-06387-2] [PMID]
23. Wilson JM, Shelvin KB, Lawhon SE, Crabill GA, Hayden EA, Velander AJ. Safety and timing of early therapeutic anticoagulation therapy after craniotomy. Surg Neurol Int. 2023. doi:10.25259/SNI_887_2023. [DOI:10.25259/SNI_887_2023] [PMID] [PMCID]
24. Shoamanesh A, Klijn CJM, Sheth KN, Veltkamp R, Sandset EC, Cordonnier C, et al. Oral anticoagulation following intracranial haemorrhage in patients with atrial fibrillation. Eur Stroke J. 2025;10(1 Suppl):35-45. doi:10.1177/23969873241296803. [DOI:10.1177/23969873241296803] [PMID] [PMCID]
Send email to the article author

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

© 2026 CC BY-NC 4.0 | Neuroscience Updates