Antithrombotic treatment consensus protocol (anticoagulation and antiplatelet therapy) during the perioperative and periprocedural period in neurosurgery

Arikan Abelló, Fuat; Ley Urzaiz, Luis; Fernández Alén, José; Martín Láez, Rubén

doi:10.1016/j.neucie.2017.08.001

array:23 ["pii" => "S2529849617300461" "issn" => "25298496" "doi" => "10.1016/j.neucie.2017.08.001" "estado" => "S300" "fechaPublicacion" => "2017-11-01" "aid" => "291" "copyright" => "Sociedad Española de Neurocirugía" "copyrightAnyo" => "2017" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2017;28:284-93" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3 "formatos" => array:2 [ "HTML" => 1 "PDF" => 2 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1130147317300891" "issn" => "11301473" "doi" => "10.1016/j.neucir.2017.08.001" "estado" => "S300" "fechaPublicacion" => "2017-11-01" "aid" => "291" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2017;28:284-93" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 153 "formatos" => array:3 [ "EPUB" => 2 "HTML" => 118 "PDF" => 33 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "Artículo Especial" "titulo" => "Protocolo de consenso en el tratamiento antitrombótico (anticoagulación y antiagregación) durante el periodo perioperatorio y periprocedimiento en neurocirugía" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "284" "paginaFinal" => "293" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Antithrombotic treatment consensus protocol (anticoagulation and antiplatelet therapy) during the perioperative and periprocedural period in neurosurgery" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1579 "Ancho" => 2167 "Tamanyo" => 277485 ] ] "descripcion" => array:1 [ "es" => "Actitud perioperatoria en paciente tratado con anticoagulantes derivados de la cumarina: acenocumarol (Sintrom®)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Fuat Arikan Abelló, Luis Ley Urzaiz, José Fernández Alén, Rubén Martín Láez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Fuat" "apellidos" => "Arikan Abelló" ] 1 => array:2 [ "nombre" => "Luis" "apellidos" => "Ley Urzaiz" ] 2 => array:2 [ "nombre" => "José" "apellidos" => "Fernández Alén" ] 3 => array:2 [ "nombre" => "Rubén" "apellidos" => "Martín Láez" ] 4 => array:1 [ "colaborador" => "Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529849617300461" "doi" => "10.1016/j.neucie.2017.08.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849617300461?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147317300891?idApp=UINPBA00004B" "url" => "/11301473/0000002800000006/v1_201711020915/S1130147317300891/v1_201711020915/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S252984961730045X" "issn" => "25298496" "doi" => "10.1016/j.neucie.2017.07.003" "estado" => "S300" "fechaPublicacion" => "2017-11-01" "aid" => "290" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2017;28:276-83" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "HTML" => 2 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Clinical Research" "titulo" => "Prognostic and predictive factors in high-grade gliomas. Experience at our institution" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "276" "paginaFinal" => "283" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Factores pronósticos y predictivos en gliomas de alto grado. Experiencia en nuestro centro" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2583 "Ancho" => 3058 "Tamanyo" => 317356 ] ] "descripcion" => array:1 [ "en" => "Kaplan–Meier curves for cumulative/overall survival in months of patients with grade IV glioma classified into different age groups: all patients, ≥ 70, 65 or 60 years, and according to the MGMT gene methylation test result (positive in blue, negative in green and not assessable in yellow)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Diana Alonso, Manuel Matallanas, Alba Riveros-Pérez, Maripaz Pérez-Payo, Sonia Blanco" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Diana" "apellidos" => "Alonso" ] 1 => array:2 [ "nombre" => "Manuel" "apellidos" => "Matallanas" ] 2 => array:2 [ "nombre" => "Alba" "apellidos" => "Riveros-Pérez" ] 3 => array:2 [ "nombre" => "Maripaz" "apellidos" => "Pérez-Payo" ] 4 => array:2 [ "nombre" => "Sonia" "apellidos" => "Blanco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S113014731730088X" "doi" => "10.1016/j.neucir.2017.07.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113014731730088X?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S252984961730045X?idApp=UINPBA00004B" "url" => "/25298496/0000002800000006/v1_201711300819/S252984961730045X/v1_201711300819/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Special article" "titulo" => "Antithrombotic treatment consensus protocol (anticoagulation and antiplatelet therapy) during the perioperative and periprocedural period in neurosurgery" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "284" "paginaFinal" => "293" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Fuat Arikan Abelló, Luis Ley Urzaiz, José Fernández Alén, Rubén Martín Láez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Fuat" "apellidos" => "Arikan Abelló" "email" => array:1 [ 0 => "farikan@vhebron.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Luis" "apellidos" => "Ley Urzaiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "José" "apellidos" => "Fernández Alén" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Rubén" "apellidos" => "Martín Láez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:1 [ "colaborador" => "Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía" ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Investigación de Neurotraumatología-Neurocirugía, Servicio de Neurocirugía, Institut de Recerca Vall d’Hebron, Universitat Autònoma de Barcelona, Hospital Universitario Vall d’Hebron, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital 12 de Octubre, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neurocirugía-Unidad de Raquis Quirúrgico, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Protocolo de consenso en el tratamiento antitrombótico (anticoagulación y antiagregación) durante el periodo perioperatorio y periprocedimiento en neurocirugía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1579 "Ancho" => 2167 "Tamanyo" => 206100 ] ] "descripcion" => array:1 [ "en" => "Perioperative procedure for patients treated with coumarin-derived anticoagulants: acenocoumarol (Sintrom®)." ] ] ] "textoCompleto" => "IntroductionThe use of antiplatelet and anticoagulant therapy in the general population has increased over the past decade, mainly because of the ageing population.<a class="elsevierStyleCrossRefs" href="#bib0165">1,2</a> In 2006, 5% of the Spanish population was taking some type of antiplatelet or anticoagulant therapy, with an annual increase of 0.26% between 1992 and 2006. Globally, 4.24% of the population was receiving oral antiplatelet therapy, 0.52% oral anticoagulant therapy and 0.3% was being treated with heparin and its derivatives.<a class="elsevierStyleCrossRef" href="#bib0165">1</a> If this growth had remained constant over that period, the estimated prevalence of use of antiplatelet or anticoagulant therapy at the beginning of this year would have reached 7.7% of the general population, with 6.4% taking antiplatelet drugs, 0.8% anticoagulant drugs and 0.5% heparin and its derivatives. These figures could be even higher since, in a recent study published by Boned-Ombuena et al., the prevalence of oral anticoagulant therapy in a representative adult population of the Valencian Community was 1.3%.<a class="elsevierStyleCrossRef" href="#bib0175">3</a> Prevalence seems to significantly increase from the age of 60, reaching 7.3% in males over the age of 80 years.In view of the data outlined above, we can assume that more than 3.5 million Spaniards are currently taking antiplatelet or anticoagulant therapy. Therefore, we can estimate that more than 5000 neurosurgical procedures are performed each year in patients receiving anticoagulant or antiplatelet therapy. These figures justify standardisation of the procedure to be followed during the perioperative period in this type of patient.Standard protocol for cerebral or spinal haemorrhage in patients receiving antithrombotic therapyStandard protocol for cerebral or spinal haemorrhage in patients receiving anticoagulant therapyUrgency, the time required to reverse anticoagulation and the period during which the patient must remain without anticoagulants are still controversial issues. For example, the time required to reverse anticoagulation with high doses of vitamin K is longer than the time required using prothrombin complex concentrates and could render patients resistant to restarting anticoagulants for several days. On the other hand, anticoagulant therapy reversal is faster and more effective in patients treated with prothrombin complex concentrates, but the thrombotic risk may be higher.Hawryluk et al. performed a review in 2010 based on 63 publications, indicating that haemorrhagic complications after restarting anticoagulant therapy are more common within the first 24–72h. They identified age (younger people), traumatic cause, subdural haematoma and failure to reverse anticoagulation as risk factors.<a class="elsevierStyleCrossRef" href="#bib0180">4</a> Thromboembolic complications are delayed (>72h) and are more common in younger patients and those with spinal haemorrhage, multiple haemorrhages and non-traumatic causes.Proposed consensus protocol<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the proposed algorithm for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Coumarin-derived anticoagulants: acenocoumarol (Sintrom®) and warfarin (Aldocoumar®)They are the most commonly used anticoagulants and have the advantage of oral administration, ability to measure the effectiveness of the drug using the International Normalised Ratio (INR) and availability of a reversal agent.The level of anticoagulation reached using these agents, measured using the INR, is linked to the worst outcomes in patients who have suffered a brain bleed. This means that as the level of anticoagulation increases, the likelihood of morbidity and mortality also increases.<a class="elsevierStyleCrossRef" href="#bib0185">5</a> Any patient arriving in the emergency department with a cerebral haemorrhagic injury requires an INR test to determine the course of treatment.Recommendations: We strongly recommend stopping and reversing coumarin anticoagulants in all patients affected by cerebral or spinal haemorrhage, regardless of the degree of INR elevation, size of the haemorrhage or its location.<a class="elsevierStyleCrossRefs" href="#bib0190">6,7</a> Reversal of anticoagulation within 2h of arrival may reduce mortality rates by 38%.<a class="elsevierStyleCrossRef" href="#bib0200">8</a>Options:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a.Fresh frozen plasma: This contains clotting factors that are useful for treating acute haemorrhage associated with coumarin anticoagulants. It is important to consider that the time required to match the patient's blood type to the plasma and thaw the sample may delay plasma administration.<a class="elsevierStyleCrossRef" href="#bib0205">9</a> The most widely recommended dosage in the literature is between 10 and 15ml of plasma per kg of body weight and, therefore, the usual volume varies between 180 and 400ml. Special care should be taken in patients with heart failure receiving large volumes of plasma as they are particularly at risk of developing severe pulmonary oedema.</li><li class="elsevierStyleListItem" id="lsti0010">b.Vitamin K: This is useful for treating coumarin-induced haemorrhage, but it is important to take into account that it is not able to fully normalise INR values when used as a single agent. The response to vitamin K is much slower than the response to fresh frozen plasma, requiring at least 2–6h, although the effect is more commonly noticeable after 24h. Concomitant use with other drugs is effective for preventing rebound INR increase once INR has been corrected using other means. Although it can be administered in various ways, intravenous administration is the most effective in acute patients. The standard dosage is 10mg administered over 30min to prevent an anaphylactic reaction, which is a common side effect of rapid infusion.<a class="elsevierStyleCrossRef" href="#bib0210">10</a></li><li class="elsevierStyleListItem" id="lsti0015">c.Prothrombin complex concentrates: In comparison to fresh frozen plasma, these have less adverse effects and provide significantly faster reversal of anticoagulation, as it has been proven that an INR below 1.3 can be achieved in 69% of patients within 1h.<a class="elsevierStyleCrossRefs" href="#bib0215">11,12</a> Moreover, they can be administered more rapidly than fresh frozen plasma since they do not need to be cross-matched or thawed before use and do not require the administration of large volumes, thus decreasing the risk of pulmonary oedema. It is important to consider that prothrombin complex concentrate solutions contain a small amount of heparin and are therefore contraindicated in patients who have previously had heparin-induced thrombocytopaenia.<a class="elsevierStyleCrossRef" href="#bib0225">13</a> The recommended dosage is 25–30IU/kg for prothrombin complex concentrate (Beriplex®, Prothromplex®, Octoplex®) and 50–100IU/kg for activated prothrombin complex concentrate (Feiba®).<a class="elsevierStyleCrossRefs" href="#bib0230">14,15</a></li><li class="elsevierStyleListItem" id="lsti0020">d.Recombinant factor VIIa (rFVIIa) (Novoseven®): Initially used in patients with haemophilia, rFVIIa is becoming increasingly popular given that it is a fast-acting agent with less potential for volume overload and poses no risk of pathogen transmission. In the context of patients treated with coumarin anticoagulants, the efficacy and safety of rFVIIa in quickly lowering INR to normal levels has been demonstrated. A lower dose is also required than the dose expected for haemophilic patients.<a class="elsevierStyleCrossRef" href="#bib0240">16</a> Duration of INR correction depends on the dose of rFVIIa administered; a continuous infusion may be used if required. The recommended dose is 80mcg/kg to normalise INR over a period of more than 6h. Unfortunately, there are disadvantages related to using rFVIIa since it is associated with a higher risk of arterial thrombosis and it is much more expensive than the other treatments described above. Therefore, its current use is limited to the presence of active bleeding that cannot be controlled using the other measures described or to patients who do not agree to receiving blood products, as is the case of Jehova's Witnesses.<a class="elsevierStyleCrossRefs" href="#bib0245">17–19</a></li></ul>Direct oral anticoagulants: dabigatran (Pradaxa®), rivaroxaban (Xarelto®), edoxaban (Lixiana®) and apixaban (Eliquis®)Currently, there is one direct thrombin inhibitor (dabigatran) and 3 direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) with approved indications for prophylaxis and antithrombotic treatment in different situations.<a class="elsevierStyleCrossRef" href="#bib0260">20</a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">(a)Dabigatran. In emergency situations, the presence or absence of anticoagulation due to dabigatran can be determined by testing activated partial thromboplastin time (aPTT) and thrombin time. Although aPTT<30s is indicative of the absence of anticoagulant activity and aPTT>80s is associated with an increased risk of bleeding, there is no linear relationship between aPTT and the patient's level of anticoagulation. There is, however, a linear relationship between aPTT and ecarin clotting time, but this test is not available at many centres. If emergency reversal is required, there is a specific antidote, idarucizumab (Praxbind®). The recommended dose is 5g of idarucizumab (2×2.5g/50ml vials) by intravenous administration as 2 consecutive infusions over 5–10min each or as a bolus injection.<a class="elsevierStyleCrossRef" href="#bib0265">21</a> Administration of a second 5-g dose of idarucizumab may be considered if clotting times are still prolonged and there is still a clinical need to rapidly reverse the anticoagulant effect. Its absorption is relatively fast. Therefore, if the drug was taken within the previous 2h, gastric lavage and administration of activated charcoal suspension may be effective. Because of its low plasma protein binding (approximately 3%), haemodialysis may remove sufficient drug from the bloodstream.</li><li class="elsevierStyleListItem" id="lsti0030">(b)Direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban). The effect of these drugs may be deduced using thrombin time, but the technique of choice for monitoring them is the anti-Xa assay. No antidotes are available for clinical use, although 2 drugs that reverse the action of direct factor Xa inhibitors are being studied: andexanet alpha and ciraparantag. However, since clinical experience with these compounds is very limited, personalised treatment of each case in cooperation with the haemostasis departments at each centre is recommended. If emergency correction is required, the standard procedure is to use activated prothrombin complex concentrate (80IU/kg) or even rFVIIa (80mcg/kg). Gastric lavage associated with the administration of activated charcoal may be useful for up to 4h after ingestion in the case of rivaroxaban and apixaban and for up to 2h in the case of edoxaban. Plasma protein binding varies depending on the drug, making haemodialysis ineffective for rivaroxaban and apixaban (plasma protein binding higher than 90%) and only partially effective for edoxaban (plasma protein binding of 50%).</li></ul>Restarting anticoagulant therapyAvailable data are inadequate for determining the optimal time to restart anticoagulation following cerebral or spinal haemorrhage.The first step is thrombotic risk stratification, for which the classification recommended in the evidence-based clinical practice guidelines published by the American College of Chest Physicians in 2012 (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>)<a class="elsevierStyleCrossRef" href="#bib0270">22</a> is very useful. In the case of atrial fibrillation, use of the CHADS2 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>)<a class="elsevierStyleCrossRef" href="#bib0275">23</a> or CHA2DS2-VASC (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>)<a class="elsevierStyleCrossRef" href="#bib0280">24</a> score is recommended. The latter is preferable in patients with low or moderate risk of thromboembolic events.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Without a doubt, the group with the most complex patients are those categorised as being at high thrombotic risk, particularly if their INR has been corrected using prothrombin complex concentrates or rFVIIa. We recommend starting these patients on low loses of low-molecular-weight heparin (LMWH) 48h after surgery as prophylaxis for deep vein thrombosis (DVT). Anticoagulant therapy may be restarted completely within 7–14 days,<a class="elsevierStyleCrossRefs" href="#bib0180">4,25,26</a> if the other specialists involved in the patient's care agree.As DVT prophylaxis during the immediate post-operative period, the use of pneumatic compression stockings and ambulation as early as possible is recommended for all other patients. The ideal time for restarting anticoagulation should be assessed on an individual basis, based primarily on the reason why anticoagulant therapy was prescribed and the cause of bleeding. In most patients, it is not necessary to restart anticoagulant therapy within the first 2 weeks.<a class="elsevierStyleCrossRefs" href="#bib0205">9,13</a>Standard protocol for cerebral or spinal haemorrhage in patients receiving antiplatelet therapyCyclooxygenase inhibitors: acetylsalicylic acidBoth cyclooxygenase isoforms, COX-1 and COX-2, are inhibited irreversibly by acetylsalicylic acid (ASA), inhibiting platelet function.In those patients with haemorrhage requiring neurosurgical treatment, platelet transfusions are recommended. In those patients with haemorrhage, but who are not candidates for surgery, a single dose of desmopressin (0.4 mcg/kg IV) should be used.<a class="elsevierStyleCrossRefs" href="#bib0195">7,27</a>ADP receptor inhibitors: clopidogrelLike ASA, the effect of clopidogrel continues until new platelets are generated, which is why platelet transfusions are recommended in those patients with haemorrhage requiring neurosurgical treatment. In those patients with haemorrhage, but who are not candidates for surgery, a single 0.4mcg/kg IV dose of desmopressin will be used.<a class="elsevierStyleCrossRefs" href="#bib0205">9,28</a>Restarting antiplatelet therapyAntiplatelet therapy should only be restarted in patients at high risk for atherothrombosis (atrial fibrillation, cardiomyopathy, stenosis of large intra/extracranial vessels). If no concomitant heart disease is present, restarting such therapy for hypertension, diabetes mellitus or dyslipidaemia is not justified.Likewise, antiplatelet therapy in combination with anticoagulants increases the risk of bleeding, and is therefore assumed to increase the risk of recurrent cerebral haemorrhage. Antiplatelet drugs (including low-dose ASA) should be avoided in patients restarting anticoagulation therapy following cerebral haemorrhage. In this situation, if the use of such drugs cannot be avoided, the dose required to achieve the lowest effective INR possible (1.8–2.5 in atrial fibrillation) is recommended before restarting therapy and INR and blood pressure should be closely monitored.Perioperative procedure in patients receiving antithrombotic therapy who are going to undergo cranial or spinal surgeryThromboembolic risk stratification for patients receiving anticoagulantsAs discussed above, <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the risk stratification for the development of perioperative thromboembolic complications in patients receiving anticoagulant therapy depending on why anticoagulation was prescribed (mechanical heart valve, atrial fibrillation or venous thromboembolism) and patient-specific characteristics.<a class="elsevierStyleCrossRef" href="#bib0270">22</a>Thromboembolic risk stratification for patients receiving antiplatelet therapyThe thrombotic risk stratification for patients treated with antiplatelet therapy is shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. The most controversial group is the group of patients with stents (primarily coronary stents, although the considerations outlined for such stents can be expanded to include carotid stents, intracranial flow diverters or aortic endoprosthesis) since such patients are often treated with dual antiplatelet therapy and require individualised assessment to establish the true thromboembolic risk.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>From the cardiac point of view, for asymptomatic patients with coronary stents, thromboembolic risk secondary to discontinuation of dual antiplatelet therapy depends on:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">•Why the stent was implanted: the thromboembolic risk is greater in patients requiring the implant as a result of an acute coronary syndrome than when the procedure is elective.</li><li class="elsevierStyleListItem" id="lsti0040">•Type of stent and time since placement: drug-eluting stents seem to have a similar risk to bare-metal stents, but require dual antiplatelet therapy to continue for longer due to delayed endothelialisation. Although this difference appears to be less noticeable with second-generation drug-eluting stents, the rule is that dual antiplatelet therapy should be continued for a minimum of 12 months with drug-eluting stents and 6 months with bare-metal stents. However, every effort should be made to continue dual antiplatelet therapy for the first 30 days after the procedure. Therefore, elective surgery should be postponed if possible.</li></ul>Classification of elective invasive procedures according to bleeding risk<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the bleeding risk stratification of different elective invasive procedures. However, although the bleeding risk of neurosurgical procedures is generally considered to be high, this bleeding risk is not identical for all patients and varies according to the type of procedure performed (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). In general, this stratification can be summarised as follows:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045">•Any intradural approach is considered HIGH RISK.</li><li class="elsevierStyleListItem" id="lsti0050">•Any intracranial approach is considered HIGH RISK.</li><li class="elsevierStyleListItem" id="lsti0055">•Any intraspinal approach is considered HIGH RISK.</li><li class="elsevierStyleListItem" id="lsti0060">•Treatments related to peripheral nerve decompression are considered INTERMEDIATE RISK.</li><li class="elsevierStyleListItem" id="lsti0065">•Peripheral nerve and muscle biopsies are considered LOW RISK.</li></ul><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Perioperative procedure in patients receiving antiplatelet therapyThe recommended time for discontinuation of antiplatelet therapy for elective neurosurgery is 7 days for clopidogrel and 5 days for ASA.<a class="elsevierStyleCrossRef" href="#bib0305">29</a>In the case of semi-urgent surgery (e.g. elective brain tumour surgery), antiplatelet therapy will be discontinued for the minimum time required to ensure adequate surgical haemostasis, considering the patient's thrombotic risk and the procedure's bleeding risk. For example, in the case of ASA, a short 2-day interval or a long 5-day interval will be selected according to the thrombotic/bleeding risk. Platelet function tests may help determine when primary haemostasis is adequate in order to allow cranial or spinal surgery.When a patient is receiving antiplatelet therapy due to having a coronary stent and surgery needs to be performed during periods of maximum risk (within 6 months for bare-metal stents and 12 months for drug-eluting stents), it is recommended that the surgery be delayed, if possible, and the patient be informed of potential risks. If, in the end, the surgery needs to go ahead, the patient's cardiologist should be consulted in order to maintain the minimum antiplatelet therapy necessary during the perioperative period or replacement therapy with parenteral antiplatelet drugs should be assessed. It is important to consider that thromboembolism tends to occur within 7–10 days of discontinuing antiplatelet therapy.For those patients receiving dual antiplatelet therapy or ASA alone at doses higher than 100mg/day or other drugs (triflusal, cilostazol, clopidogrel, prasugrel or ticagrelor), treatment must be replaced by ASA at a dose of 100mg/day, provided that discontinuation of antiplatelet therapy is not recommended.Restarting antiplatelet therapy during the postoperative periodIt is recommended that antiplatelet therapy be restarted 12–24h after surgery when haemostasis is adequate and provided that haemorrhagic complications have been ruled out.Perioperative procedure in patients receiving anticoagulants. Guidelines for stopping and restarting anticoagulants during the perioperative periodCoumarin-derived anticoagulants: acenocoumarol (Sintrom®) and warfarin (Aldocoumar®)Acenocoumarol and warfarin should be stopped 4 and 5 days before surgery, respectively, and the patient should start enoxaparin at therapeutic doses (1mg/kg every 12h if creatinine clearance is >30ml/min) 24–36h after stopping acenocoumarol or warfarin.<a class="elsevierStyleCrossRefs" href="#bib0310">30,31</a> The final dose (half the usual daily dose) should be administered 24h before surgery.The evening before the surgery, in addition to not taking enoxaparin, haemostatic screening tests, including prothrombin time, are recommended. Preoperative management should not change if INR<1.5, but vitamin K should be administered if INR is any higher. The INR should be re-checked on the morning of the surgery and the surgery should be postponed if INR is still above 1.2 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Direct oral anticoagulants: dabigatran (Pradaxa®), rivaroxaban (Xarelto®), edoxaban (Lixiana®) and apixaban (Eliquis®)Perioperative management of direct oral anticoagulants is described in the SmPC of these medicinal products. Nevertheless, given the limited evidence available, and the even more limited experience with these drugs, careful use during the perioperative period is recommended. Different clinical practice guidelines, expert recommendations and reviews generally recommend discontinuing drugs 1–5 days prior to surgery, depending on the specific drug used, renal function, bleeding risk of the surgery and thrombotic risk associated with discontinuation of anticoagulant therapy. Bridging therapy with LMWH is not usually considered, even in patients at high thrombotic risk.However, in the event of surgery posing a high risk of bleeding or haemorrhagic complications during the postoperative period, administration of LMWH is recommended for postoperative management of these patients before restarting oral anticoagulants.<a class="elsevierStyleCrossRef" href="#bib0320">32</a><a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> gives guidelines for stopping direct oral anticoagulants during the perioperative period.<elsevierMultimedia ident="tbl0035"></elsevierMultimedia>Perioperative procedure for patients with no prior antithrombotic therapy who are going to undergo neurosurgeryTo prevent DVT, the use of intermittent pneumatic compression stockings is recommended from the start of surgery, with these being removed once the patient begins to walk. From day 2 of the postoperative period, and once haemorrhagic complications have been ruled out, the use of low doses of LMWH or unfractionated heparin is recommended in patients at high risk of DVT.In the event of DVT or pulmonary thromboembolism, the use of heparin or LMWH at doses resulting in anticoagulation is recommended once haemorrhagic complications have been ruled out, followed by oral anticoagulants at low doses (INR 2) for 3 months.FundingWe declare that there was no source of funding to carry out this protocol.Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres949037" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec921145" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres949038" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec921146" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Standard protocol for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Standard protocol for cerebral or spinal haemorrhage in patients receiving anticoagulant therapy" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Proposed consensus protocol" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Coumarin-derived anticoagulants: acenocoumarol (Sintrom) and warfarin (Aldocoumar)" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Direct oral anticoagulants: dabigatran (Pradaxa), rivaroxaban (Xarelto), edoxaban (Lixiana) and apixaban (Eliquis)" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Restarting anticoagulant therapy" ] ] ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Standard protocol for cerebral or spinal haemorrhage in patients receiving antiplatelet therapy" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Cyclooxygenase inhibitors: acetylsalicylic acid" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "ADP receptor inhibitors: clopidogrel" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Restarting antiplatelet therapy" ] 3 => array:3 [ "identificador" => "sec0060" "titulo" => "Perioperative procedure in patients receiving antithrombotic therapy who are going to undergo cranial or spinal surgery" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Thromboembolic risk stratification for patients receiving anticoagulants" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Thromboembolic risk stratification for patients receiving antiplatelet therapy" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Classification of elective invasive procedures according to bleeding risk" ] ] ] 4 => array:3 [ "identificador" => "sec0080" "titulo" => "Perioperative procedure in patients receiving antiplatelet therapy" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Restarting antiplatelet therapy during the postoperative period" ] ] ] 5 => array:3 [ "identificador" => "sec0090" "titulo" => "Perioperative procedure in patients receiving anticoagulants. Guidelines for stopping and restarting anticoagulants during the perioperative period" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Coumarin-derived anticoagulants: acenocoumarol (Sintrom) and warfarin (Aldocoumar)" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Direct oral anticoagulants: dabigatran (Pradaxa), rivaroxaban (Xarelto), edoxaban (Lixiana) and apixaban (Eliquis)" ] ] ] 6 => array:2 [ "identificador" => "sec0105" "titulo" => "Perioperative procedure for patients with no prior antithrombotic therapy who are going to undergo neurosurgery" ] ] ] 7 => array:2 [ "identificador" => "sec0110" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-25" "fechaAceptado" => "2017-08-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec921145" "palabras" => array:6 [ 0 => "Antithrombotic treatment" 1 => "Anticoagulant therapy" 2 => "Antiplatelet therapy" 3 => "Haemorrhage risk" 4 => "Perioperative" 5 => "Neurosurgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec921146" "palabras" => array:6 [ 0 => "Tratamiento antitrombótico" 1 => "Anticoagulantes" 2 => "Antiagregantes" 3 => "Riesgo hemorragico" 4 => "Perioperatorio" 5 => "Neurocirugia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The use of antithrombotic medication (antiplatelet and/or anticoagulant therapy) is widespread. Currently, the management of neurosurgical patients receiving this type of therapy continues to be a problem of special importance.Patients receiving antithrombotic treatment may need neurosurgical care because of bleeding secondary to such treatment, non-haemorrhagic neurosurgical lesions requiring urgent attention, or simply elective neurosurgical procedures.In addition, the consequences of reintroducing early (bleeding or rebleeding) or late (thrombotic or thromboembolic) anticoagulation can be devastating.In this paper we present the antithrombotic treatment consensus protocol during the perioperative and periprocedural period, both in emergent surgery and in elective neurosurgical procedures." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El uso de medicación antitrombótica (antiagregante y/o anticoagulante) se encuentra ampliamente extendido. El manejo de los pacientes neuroquirúrgicos que reciben este tipo de terapia continúa siendo, a día de hoy, un problema de especial importancia.Los pacientes en tratamiento antitrombótico pueden necesitar atención neuroquirúrgica bien por presentar sangrados secundarios a dicho tratamiento, lesiones neuroquirúrgicas no hemorrágicas pero que precisen intervención urgente, o simplemente procedimientos neuroquirúrgicos electivos.Además, las consecuencias de la reintroducción de la anticoagulación temprana (sangrado o resangrado) o tardía (trombóticas o tromboembólicas) pueden ser devastadoras.En este documento presentamos el protocolo de consenso en el tratamiento antitrombótico durante el periodo perioperatorio y periprocedimiento, tanto en cirugía emergente como en procedimientos electivos de neurocirugía." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Arikan Abelló F, Ley Urzaiz L, Fernández Alén J, Martín Láez R, Grupo de Trabajo de Patología Vascular de la Sociedad Española de Neurocirugía. Protocolo de consenso en el tratamiento antitrombótico (anticoagulación y antiagregación) durante el periodo perioperatorio y periprocedimiento en neurocirugía. Neurocirugía. 2017;28:284–293." ] ] "multimedia" => array:9 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1505 "Ancho" => 2667 "Tamanyo" => 350412 ] ] "descripcion" => array:1 [ "en" => "Proposed algorithm for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1579 "Ancho" => 2167 "Tamanyo" => 206100 ] ] "descripcion" => array:1 [ "en" => "Perioperative procedure for patients treated with coumarin-derived anticoagulants: acenocoumarol (Sintrom®)." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AF: atrial fibrillation; AT: antithrombin; CHADS2: score for estimating stroke risk in patients with atrial fibrillation; CHA2DS2-VASC: modification of CHADS2 score by including additional stroke risk modifiers; HTN: hypertension; PC: protein C; PS: protein S; TIA: transient ischaemic attack." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">High risk of thromboembolism \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate risk of thromboembolism \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk of thromboembolism \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mechanical heart valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Any mitral valve prosthesis • Any caged-ball or tilting-disc aortic valve prosthesis • Recent (<6 months) stroke or TIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Bileaflet aortic valve prosthesis and one or more of the following risk factors for stroke: AF, prior stroke or TIA, HTN, diabetes mellitus, heart failure, age>75 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Bileaflet aortic valve without AF and no other risk factors for stroke \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• CHADS2≥3 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>); CHA2DS2-VASC≥6 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) • Recent (<3 months) stroke or TIA • Valvular rheumatic heart disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• CHADS2=1–2; CHA2DS2-VASC=2–5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• CHADS2=0 and no prior stroke or TIA; CHA2DS2-VASC=0–1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Venous thromboembolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Recent (<3 months) venous thromboembolism • Severe thrombophilia (deficiency of PC, PS or AT; antiphospholipid syndrome or multiple abnormalities) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Prior (3–12 months) venous thromboembolism • Non-severe thrombophilia: heterozygous factor V Leiden, heterozygous prothrombin G20210A mutation or other states (elderly, high body mass index, chronic diseases or presence of antiphospholipid antibodies) • Recurrent episodes of venous thromboembolism and prior episodes following surgery • Active cancer (treated within the last 6 months or in palliative care) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Single venous thromboembolism>12 months prior and no other risk factors \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607232.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Thrombotic risk stratification for patients treated with oral anticoagulants." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Stroke risk according to CHADS2 score expressed as % (95% CI): 0 points: 1.9 (1.2–3); 1 point: 2.8 (2–3.8); 2 points: 4 (3.1–5.1); 3 points: 5.9 (4.6–7.3); 4 points: 8.5 (6.3–11.1); 5 points: 12.5 (8.2–17.5); 6 points: 18.2 (10.5–27.4)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Condition \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congestive heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension: blood pressure consistently above 140/90mmHg (or hypertension treated with medication) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Age ≥ 75 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">S2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prior stroke, transient ischaemic attack or thromboembolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607236.png" ] ] ] ] "descripcion" => array:1 [ "en" => "CHADS2 score. Predictive score for estimating stroke risk in patients with atrial fibrillation." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Stroke risk according to CHA2DS2-VASC score expressed as %: 0 points=0%; 1 point=1.3%; 2 points=2.2%; 3 points=3.2%; 4 points=4%; 5 points=6.7%; 6 points=9.6%; 7 points=9.8%; 8 points=12.5%; 9 points=15.2%." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Condition \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Points \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Congestive heart failure or (left ventricular systolic dysfunction) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension: blood pressure consistently above 140/90mmHg (or hypertension treated with medication) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Age≥75 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">S2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prior stroke, transient ischaemic attack or thromboembolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vascular disease (e.g. peripheral arterial disease, myocardial infarction, aortic atheroma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Age=65–74 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607235.png" ] ] ] ] "descripcion" => array:1 [ "en" => "CHA2DS2-VASC. To complement the CHADS2 score with other stroke risk factors, the CHA2DS2-VASC score was proposed." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">High thrombotic risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Moderate thrombotic risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">Low thrombotic risk \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Patients with bare-metal stent (<6 weeks) or drug-eluting stent (<12 months) • Acute myocardial infarction or ischaemic stroke (<3 months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Patients with bare-metal stent (>6 weeks) or drug-eluting stent (>12 months) • Secondary prevention of acute myocardial infarction or ischaemic stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Primary prevention of cardiovascular disease and diabetes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607237.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Thrombotic risk stratification for patients treated with antiplatelet drugs." ] ] 6 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery that does not necessarily require anticoagulation to be stopped \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery with a low risk of bleeding (uncommon or with low clinical impact) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery with a high risk of bleeding (common or with high clinical impact) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Single or multiple dental surgeries including alveolectomy and implant placement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Major thoracic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Coronary artery bypass graft surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cataract and glaucoma surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Major orthopaedic surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heart surgery with valve replacement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coronary angiography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intra-abdominal surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Major vascular surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dermatological surgeries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pacemaker implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neurosurgical procedures<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Laparoscopic cholecystectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Prostatectomy or bladder surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hernia surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Major cancer surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal biopsy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colon polypectomy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Any major surgery lasting >45min \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607234.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Haemorrhagic risk in neurosurgical procedures is generally considered to be high, but it is not identical in all patients." ] ] ] "descripcion" => array:1 [ "en" => "Bleeding risk stratification of different elective invasive procedures." ] ] 7 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bleeding risk \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Definition \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Procedures \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adequate haemostasis Possible bleeding is not a critical risk for the patient and does not affect surgery outcome Transfusions not required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minor surgery under local anaesthesia: • Muscle biopsy • Peripheral nerve biopsy • Surgical wound check-up • Cerebral angiography • Percutaneous spine procedures: facet fusion and rhizolysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complicated surgical haemostasis Possible bleeding is not a critical risk for the patient and does not affect surgery outcome Bleeding increases the need for transfusion or repeat surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minimally invasive procedures: • Carotid stent • Peripheral nerve decompression • Percutaneous approach to treat the trigeminal nerve • Kyphoplasty/vertebroplasty • Lumbar puncture • Percutaneous spine procedures: epidural, transforaminal and caudal • Percutaneous spine instrumentation without access to the spinal canal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Perioperative bleeding could have an impact on the patient's life or surgery outcome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Invasive procedures: • Craniotomy/craniectomy • Brain or spinal cord biopsies • Complex spine surgery or with access to the spinal canal (laminectomy, discectomy, deformity correction, etc.) • Carotid endarterectomy • Embolisation (intracranial/spinal cord) • Mechanical embolectomy • Deep brain stimulation, deep brain electrodes • CSF shunts (ventriculoperitoneal shunt, ventriculoatrial shunt, lumbar-peritoneal shunt, continuous lumbar drainage and external ventricular drainage) • Endoscopic transsphenoidal and skull base surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607233.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Bleeding risk stratification of neurosurgical procedures." ] ] 8 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at7" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bleeding risk</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">High \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Low \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Dabigatran</td><td class="td" title="table-entry " align="left" valign="top">GFR>50ml/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Continue with anticoagulation, avoiding surgery during the peak action time (2h after ingestion) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GFR<50ml/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rivaroxaban Apixaban \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFR>30ml/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">GFR<30ml/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1607231.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Guidelines for stopping direct oral anticoagulants based on the compound used, glomerular filtration and bleeding risk." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:32 [ 0 => array:3 [ "identificador" => "bib0165" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Agencia Española de Medicamentos y Productos Sanitarios. Utilización de antiagregantes y anticoagulantes en España (1992–2006). Available from: <a href="http://cima.aemps.es/medicamentosUsoHumano/observatorio/docs/antiagregantes.pdf">http://cima.aemps.es/medicamentosUsoHumano/observatorio/docs/antiagregantes.pdf</a> [accessed 17.06.17]." ] ] ] 1 => array:3 [ "identificador" => "bib0170" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "1300–1305 e1302" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "National trends in ambulatory oral anticoagulant use" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G.D. Barnes" 1 => "E. Lucas" 2 => "G.C. Alexander" 3 => "Z.D. Goldberger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Am J Med" "fecha" => "2015" "volumen" => "128" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0175" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Prevalence of oral anticoagulation and quality of its management in primary healthcare: a study by the Health Sentinel Network of the Region of Valencia (Spain)]" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Boned-Ombuena" 1 => "J. Perez-Panades" 2 => "A. Lopez-Maside" 3 => "M. Miralles-Espi" 4 => "S. Guardiola Vilarroig" 5 => "D. Adam Ruiz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Aten Primaria" "fecha" => "2017" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0180" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G.W. Hawryluk" 1 => "J.W. Austin" 2 => "J.C. Furlan" 3 => "J.B. Lee" 4 => "C. O’Kelly" 5 => "M.G. Fehlings" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1538-7836.2010.03882.x" "Revista" => array:6 [ "tituloSerie" => "J Thromb Haemost" "fecha" => "2010" "volumen" => "8" "paginaInicial" => "1500" "paginaFinal" => "1508" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20403088" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0185" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F.M. Pieracci" 1 => "S.R. Eachempati" 2 => "J. Shou" 3 => "L.J. Hydo" 4 => "Barie PS:" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/TA.0b013e31812e5216" "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2007" "volumen" => "63" "paginaInicial" => "525" "paginaFinal" => "530" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18073596" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0190" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed.)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Ansell" 1 => "J. Hirsh" 2 => "E. Hylek" 3 => "A. Jacobson" 4 => "M. Crowther" 5 => "G. Palareti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.08-0670" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2008" "volumen" => "133" "paginaInicial" => "160S" "paginaFinal" => "198S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18574265" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0195" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guideline for eeversal of antithrombotics in intracranial hemorrhage: a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Frontera" 1 => "J.J. Lewin 3rd" 2 => "A.A. Rabinstein" 3 => "I.P. Aisiku" 4 => "A.W. Alexandrov" 5 => "A.M. Cook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12028-015-0222-x" "Revista" => array:6 [ "tituloSerie" => "Neurocrit Care" "fecha" => "2016" "volumen" => "24" "paginaInicial" => "6" "paginaFinal" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26714677" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0200" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[discusión 1137-1139]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "F.A. Ivascu" 1 => "G.A. Howells" 2 => "F.S. Junn" 3 => "H.A. Bair" 4 => "P.J. Bendick" 5 => "R.J. Janczyk" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "2005" "volumen" => "59" "paginaInicial" => "1131" "paginaFinal" => "1137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16385291" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0205" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Emergency reversal of anticoagulation and antiplatelet therapies in neurosurgical patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.E. Beshay" 1 => "H. Morgan" 2 => "C. Madden" 3 => "W. Yu" 4 => "R. Sarode" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2009.7.JNS0982" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg" "fecha" => "2010" "volumen" => "112" "paginaInicial" => "307" "paginaFinal" => "318" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19663548" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0210" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T. Steiner" 1 => "J. Rosand" 2 => "M. Diringer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/01.STR.0000196989.09900.f8" "Revista" => array:6 [ "tituloSerie" => "Stroke" "fecha" => "2006" "volumen" => "37" "paginaInicial" => "256" "paginaFinal" => "262" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16339459" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0215" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcomes of urgent warfarin reversal with frozen plasma versus prothrombin complex concentrate in the emergency department" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Hickey" 1 => "M. Gatien" 2 => "M. Taljaard" 3 => "A. Aujnarain" 4 => "A. Giulivi" 5 => "J.J. Perry" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.113.001875" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2013" "volumen" => "128" "paginaInicial" => "360" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23770745" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0220" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Sarode" 1 => "T.J. Milling Jr." 2 => "M.A. Refaai" 3 => "A. Mangione" 4 => "A. Schneider" 5 => "B.L. Durn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.113.002283" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2013" "volumen" => "128" "paginaInicial" => "1234" "paginaFinal" => "1243" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23935011" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0225" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Race against the clock: overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Le Roux" 1 => "C.V. Pollack Jr." 2 => "M. Milan" 3 => "A. Schaefer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/2014.6.GKS141282" "Revista" => array:7 [ "tituloSerie" => "J Neurosurg" "fecha" => "2014" "volumen" => "121" "numero" => "Suppl." "paginaInicial" => "1" "paginaFinal" => "20" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25434932" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0230" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of warfarin-associated intracerebral hemorrhage: literature review and expert opinion" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.I. Aguilar" 1 => "R.G. Hart" 2 => "C.S. Kase" 3 => "W.D. Freeman" 4 => "B.J. Hoeben" 5 => "R.C. Garcia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4065/82.1.82" "Revista" => array:6 [ "tituloSerie" => "Mayo Clin Proc" "fecha" => "2007" "volumen" => "82" "paginaInicial" => "82" "paginaFinal" => "92" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17285789" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0235" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Vigue" 1 => "C. Ract" 2 => "B. Tremey" 3 => "N. Engrand" 4 => "P.E. Leblanc" 5 => "A. Decaux" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-007-0528-z" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2007" "volumen" => "33" "paginaInicial" => "721" "paginaFinal" => "725" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17260127" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0240" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reversal of warfarin-induced excessive anticoagulation with recombinant human factor VIIa concentrate" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.A. Deveras" 1 => "C.M. Kessler" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2002" "volumen" => "137" "paginaInicial" => "884" "paginaFinal" => "888" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12458988" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0245" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of recombinant factor VIIa in patients with warfarin-associated intracranial hemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.L. Brody" 1 => "V. Aiyagari" 2 => "A.M. Shackleford" 3 => "M.N. Diringer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1385/NCC:2:3:263" "Revista" => array:6 [ "tituloSerie" => "Neurocrit Care" "fecha" => "2005" "volumen" => "2" "paginaInicial" => "263" "paginaFinal" => "267" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16159073" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0250" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety of recombinant activated factor VII in randomized clinical trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Levi" 1 => "J.H. Levy" 2 => "H.F. Andersen" 3 => "D. Truloff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1006221" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2010" "volumen" => "363" "paginaInicial" => "1791" "paginaFinal" => "1800" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21047223" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0255" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.A. Mayer" 1 => "N.C. Brun" 2 => "K. Begtrup" 3 => "J. Broderick" 4 => "S. Davis" 5 => "M.N. Diringer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0707534" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2008" "volumen" => "358" "paginaInicial" => "2127" "paginaFinal" => "2137" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18480205" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0260" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Novel oral anticoagulants and their role in clinical practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.K. Wittkowsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1592/phco.31.12.1175" "Revista" => array:6 [ "tituloSerie" => "Pharmacotherapy" "fecha" => "2011" "volumen" => "31" "paginaInicial" => "1175" "paginaFinal" => "1191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22122180" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0265" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ficha técnica Praxbind. Available from: <a href="http://www.ema.europa.eu/docs/es_ES/document_library/EPAR_-">http://www.ema.europa.eu/docs/es_ES/document_library/EPAR_-</a> [accessed 17.06.17]." ] ] ] 21 => array:3 [ "identificador" => "bib0270" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.D. Douketis" 1 => "A.C. Spyropoulos" 2 => "F.A. Spencer" 3 => "M. Mayr" 4 => "A.K. Jaffer" 5 => "M.H. Eckman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-2298" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "141" "paginaInicial" => "e326S" "paginaFinal" => "e350S" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22315266" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0275" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B.F. Gage" 1 => "A.D. Waterman" 2 => "W. Shannon" 3 => "M. Boechler" 4 => "M.W. Rich" 5 => "M.J. Radford" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2001" "volumen" => "285" "paginaInicial" => "2864" "paginaFinal" => "2870" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11401607" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0280" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G.Y. Lip" 1 => "R. Nieuwlaat" 2 => "R. Pisters" 3 => "D.A. Lane" 4 => "H.J. Crijns" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.09-1584" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2010" "volumen" => "137" "paginaInicial" => "263" "paginaFinal" => "272" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19762550" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0285" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of intracranial bleeding associated with anticoagulation: balancing the risk of further bleeding against thromboembolism from prosthetic heart valves" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Crawley" 1 => "D. Bevan" 2 => "D. Wren" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Neurol Neurosurg Psychiatry" "fecha" => "2000" "volumen" => "69" "paginaInicial" => "396" "paginaFinal" => "398" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10945818" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0290" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimal timing of resumption of warfarin after intracranial hemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Majeed" 1 => "Y.K. Kim" 2 => "R.S. Roberts" 3 => "M. Holmstrom" 4 => "S. Schulman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/STROKEAHA.110.593087" "Revista" => array:6 [ "tituloSerie" => "Stroke" "fecha" => "2010" "volumen" => "41" "paginaInicial" => "2860" "paginaFinal" => "2866" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21030703" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0295" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.I. Baharoglu" 1 => "C. Cordonnier" 2 => "R. Al-Shahi Salman" 3 => "K. de Gans" 4 => "M.M. Koopman" 5 => "A. Brand" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(16)30392-0" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2016" "volumen" => "387" "paginaInicial" => "2605" "paginaFinal" => "2613" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27178479" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0300" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Normalization of platelet reactivity in clopidogrel-treated subjects" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Vilahur" 1 => "B.G. Choi" 2 => "M.U. Zafar" 3 => "J.F. Viles-Gonzalez" 4 => "D.A. Vorchheimer" 5 => "V. Fuster" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1538-7836.2006.02245.x" "Revista" => array:6 [ "tituloSerie" => "J Thromb Haemost" "fecha" => "2007" "volumen" => "5" "paginaInicial" => "82" "paginaFinal" => "90" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17239165" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0305" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "[Clinical practice guidelines for the perioperative management of antiplatelet therapy in noncardiac surgery (Sociedad Española de Anestesiología y Reanimación)]" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Sociedad Española de Anestesiología y Reanimación" "etal" => false "autores" => array:4 [ 0 => "P. Sierra" 1 => "A. Gomez-Luque" 2 => "J. Castillo" 3 => "J.V. Llau" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2011" "volumen" => "58" "paginaInicial" => "243" "paginaFinal" => "250" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21608281" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0310" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Periprocedural bridging anticoagulation: current perspectives" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Palaniswamy" 1 => "D.R. Selvaraj" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MJT.0b013e3181d41ed6" "Revista" => array:6 [ "tituloSerie" => "Am J Ther" "fecha" => "2011" "volumen" => "18" "paginaInicial" => "e89" "paginaFinal" => "e94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20228672" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0315" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.G. Phan" 1 => "M. Koh" 2 => "Wijdicks EF:" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Neurol" "fecha" => "2000" "volumen" => "57" "paginaInicial" => "1710" "paginaFinal" => "1713" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11115236" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0320" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anticoagulation, novel agents, and procedures: can we pardon the interruption?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.A. Garcia" 1 => "C.B. Granger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.112.115188" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2012" "volumen" => "126" "paginaInicial" => "255" "paginaFinal" => "257" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22700855" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/25298496/0000002800000006/v1_201711300819/S2529849617300461/v1_201711300819/en/main.assets" "Apartado" => array:4 [ "identificador" => "63440" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/25298496/0000002800000006/v1_201711300819/S2529849617300461/v1_201711300819/en/main.pdf?idApp=UINPBA00004B&text.app=https://revistaneurocirugia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849617300461?idApp=UINPBA00004B"]

 array:23 [
  "pii" => "S2529849617300461"
  "issn" => "25298496"
  "doi" => "10.1016/j.neucie.2017.08.001"
  "estado" => "S300"
  "fechaPublicacion" => "2017-11-01"
  "aid" => "291"
  "copyright" => "Sociedad Espa&#241;ola de Neurocirug&#237;a"
  "copyrightAnyo" => "2017"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "fla"
  "cita" => "Neurocirugia. 2017;28:284-93"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 3
    "formatos" => array:2 [
      "HTML" => 1
      "PDF" => 2
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S1130147317300891"
      "issn" => "11301473"
      "doi" => "10.1016/j.neucir.2017.08.001"
      "estado" => "S300"
      "fechaPublicacion" => "2017-11-01"
      "aid" => "291"
      "copyright" => "Sociedad Espa&#241;ola de Neurocirug&#237;a"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "fla"
      "cita" => "Neurocirugia. 2017;28:284-93"
      "abierto" => array:3 [
        "ES" => false
        "ES2" => false
        "LATM" => false
      ]
      "gratuito" => false
      "lecturas" => array:2 [
        "total" => 153
        "formatos" => array:3 [
          "EPUB" => 2
          "HTML" => 118
          "PDF" => 33
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Art&#237;culo Especial</span>"
        "titulo" => "Protocolo de consenso en el tratamiento antitromb&#243;tico &#40;anticoagulaci&#243;n y antiagregaci&#243;n&#41; durante el periodo perioperatorio y periprocedimiento en neurocirug&#237;a"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "284"
            "paginaFinal" => "293"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Antithrombotic treatment consensus protocol &#40;anticoagulation and antiplatelet therapy&#41; during the perioperative and periprocedural period in neurosurgery"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0010"
            "etiqueta" => "Figura 2"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr2.jpeg"
                "Alto" => 1579
                "Ancho" => 2167
                "Tamanyo" => 277485
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Actitud perioperatoria en paciente tratado con anticoagulantes derivados de la cumarina&#58; acenocumarol &#40;Sintrom<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Fuat Arikan Abell&#243;, Luis Ley Urzaiz, Jos&#233; Fern&#225;ndez Al&#233;n, Rub&#233;n Mart&#237;n L&#225;ez"
            "autores" => array:5 [
              0 => array:2 [
                "nombre" => "Fuat"
                "apellidos" => "Arikan Abell&#243;"
              ]
              1 => array:2 [
                "nombre" => "Luis"
                "apellidos" => "Ley Urzaiz"
              ]
              2 => array:2 [
                "nombre" => "Jos&#233;"
                "apellidos" => "Fern&#225;ndez Al&#233;n"
              ]
              3 => array:2 [
                "nombre" => "Rub&#233;n"
                "apellidos" => "Mart&#237;n L&#225;ez"
              ]
              4 => array:1 [
                "colaborador" => "Grupo de Trabajo de Patolog&#237;a Vascular de la Sociedad Espa&#241;ola de Neurocirug&#237;a"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S2529849617300461"
          "doi" => "10.1016/j.neucie.2017.08.001"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849617300461?idApp=UINPBA00004B"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147317300891?idApp=UINPBA00004B"
      "url" => "/11301473/0000002800000006/v1_201711020915/S1130147317300891/v1_201711020915/es/main.assets"
    ]
  ]
  "itemAnterior" => array:19 [
    "pii" => "S252984961730045X"
    "issn" => "25298496"
    "doi" => "10.1016/j.neucie.2017.07.003"
    "estado" => "S300"
    "fechaPublicacion" => "2017-11-01"
    "aid" => "290"
    "copyright" => "Sociedad Espa&#241;ola de Neurocirug&#237;a"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Neurocirugia. 2017;28:276-83"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2
      "HTML" => 2
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Clinical Research</span>"
      "titulo" => "Prognostic and predictive factors in high-grade gliomas&#46; Experience at our institution"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "276"
          "paginaFinal" => "283"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Factores pron&#243;sticos y predictivos en gliomas de alto grado&#46; Experiencia en nuestro centro"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Fig&#46; 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 2583
              "Ancho" => 3058
              "Tamanyo" => 317356
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Kaplan&#8211;Meier curves for cumulative&#47;overall survival in months of patients with grade IV glioma classified into different age groups&#58; all patients&#44; &#8805; 70&#44; 65 or 60 years&#44; and according to the MGMT gene methylation test result &#40;positive in blue&#44; negative in green and not assessable in yellow&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Diana Alonso, Manuel Matallanas, Alba Riveros-P&#233;rez, Maripaz P&#233;rez-Payo, Sonia Blanco"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Diana"
              "apellidos" => "Alonso"
            ]
            1 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "Matallanas"
            ]
            2 => array:2 [
              "nombre" => "Alba"
              "apellidos" => "Riveros-P&#233;rez"
            ]
            3 => array:2 [
              "nombre" => "Maripaz"
              "apellidos" => "P&#233;rez-Payo"
            ]
            4 => array:2 [
              "nombre" => "Sonia"
              "apellidos" => "Blanco"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S113014731730088X"
        "doi" => "10.1016/j.neucir.2017.07.005"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S113014731730088X?idApp=UINPBA00004B"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S252984961730045X?idApp=UINPBA00004B"
    "url" => "/25298496/0000002800000006/v1_201711300819/S252984961730045X/v1_201711300819/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
    "titulo" => "Antithrombotic treatment consensus protocol &#40;anticoagulation and antiplatelet therapy&#41; during the perioperative and periprocedural period in neurosurgery"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "284"
        "paginaFinal" => "293"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Fuat Arikan Abell&#243;, Luis Ley Urzaiz, Jos&#233; Fern&#225;ndez Al&#233;n, Rub&#233;n Mart&#237;n L&#225;ez"
        "autores" => array:5 [
          0 => array:4 [
            "nombre" => "Fuat"
            "apellidos" => "Arikan Abell&#243;"
            "email" => array:1 [
              0 => "farikan&#64;vhebron&#46;net"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Luis"
            "apellidos" => "Ley Urzaiz"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Jos&#233;"
            "apellidos" => "Fern&#225;ndez Al&#233;n"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Rub&#233;n"
            "apellidos" => "Mart&#237;n L&#225;ez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          4 => array:1 [
            "colaborador" => "Grupo de Trabajo de Patolog&#237;a Vascular de la Sociedad Espa&#241;ola de Neurocirug&#237;a"
          ]
        ]
        "afiliaciones" => array:4 [
          0 => array:3 [
            "entidad" => "Unidad de Investigaci&#243;n de Neurotraumatolog&#237;a-Neurocirug&#237;a&#44; Servicio de Neurocirug&#237;a&#44; Institut de Recerca Vall d&#8217;Hebron&#44; Universitat Aut&#242;noma de Barcelona&#44; Hospital Universitario Vall d&#8217;Hebron&#44; Barcelona&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Neurocirug&#237;a&#44; Hospital Universitario Ram&#243;n y Cajal&#44; Madrid&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Neurocirug&#237;a&#44; Hospital 12 de Octubre&#44; Madrid&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Servicio de Neurocirug&#237;a-Unidad de Raquis Quir&#250;rgico&#44; Hospital Universitario Marqu&#233;s de Valdecilla&#44; Santander&#44; Spain"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Protocolo de consenso en el tratamiento antitromb&#243;tico &#40;anticoagulaci&#243;n y antiagregaci&#243;n&#41; durante el periodo perioperatorio y periprocedimiento en neurocirug&#237;a"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1579
            "Ancho" => 2167
            "Tamanyo" => 206100
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Perioperative procedure for patients treated with coumarin-derived anticoagulants&#58; acenocoumarol &#40;Sintrom<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The use of antiplatelet and anticoagulant therapy in the general population has increased over the past decade&#44; mainly because of the ageing population&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">1&#44;2</span></a> In 2006&#44; 5&#37; of the Spanish population was taking some type of antiplatelet or anticoagulant therapy&#44; with an annual increase of 0&#46;26&#37; between 1992 and 2006&#46; Globally&#44; 4&#46;24&#37; of the population was receiving oral antiplatelet therapy&#44; 0&#46;52&#37; oral anticoagulant therapy and 0&#46;3&#37; was being treated with heparin and its derivatives&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">1</span></a> If this growth had remained constant over that period&#44; the estimated prevalence of use of antiplatelet or anticoagulant therapy at the beginning of this year would have reached 7&#46;7&#37; of the general population&#44; with 6&#46;4&#37; taking antiplatelet drugs&#44; 0&#46;8&#37; anticoagulant drugs and 0&#46;5&#37; heparin and its derivatives&#46; These figures could be even higher since&#44; in a recent study published by Boned-Ombuena et al&#46;&#44; the prevalence of oral anticoagulant therapy in a representative adult population of the Valencian Community was 1&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">3</span></a> Prevalence seems to significantly increase from the age of 60&#44; reaching 7&#46;3&#37; in males over the age of 80 years&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In view of the data outlined above&#44; we can assume that more than 3&#46;5 million Spaniards are currently taking antiplatelet or anticoagulant therapy&#46; Therefore&#44; we can estimate that more than 5000 neurosurgical procedures are performed each year in patients receiving anticoagulant or antiplatelet therapy&#46; These figures justify standardisation of the procedure to be followed during the perioperative period in this type of patient&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Standard protocol for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Standard protocol for cerebral or spinal haemorrhage in patients receiving anticoagulant therapy</span><p id="par0015" class="elsevierStylePara elsevierViewall">Urgency&#44; the time required to reverse anticoagulation and the period during which the patient must remain without anticoagulants are still controversial issues&#46; For example&#44; the time required to reverse anticoagulation with high doses of vitamin K is longer than the time required using prothrombin complex concentrates and could render patients resistant to restarting anticoagulants for several days&#46; On the other hand&#44; anticoagulant therapy reversal is faster and more effective in patients treated with prothrombin complex concentrates&#44; but the thrombotic risk may be higher&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Hawryluk et al&#46; performed a review in 2010 based on 63 publications&#44; indicating that haemorrhagic complications after restarting anticoagulant therapy are more common within the first 24&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#46; They identified age &#40;younger people&#41;&#44; traumatic cause&#44; subdural haematoma and failure to reverse anticoagulation as risk factors&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> Thromboembolic complications are delayed &#40;&#62;72<span class="elsevierStyleHsp" style=""></span>h&#41; and are more common in younger patients and those with spinal haemorrhage&#44; multiple haemorrhages and non-traumatic causes&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Proposed consensus protocol</span><p id="par0025" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the proposed algorithm for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Coumarin-derived anticoagulants&#58; acenocoumarol &#40;Sintrom<span class="elsevierStyleSup">&#174;</span>&#41; and warfarin &#40;Aldocoumar<span class="elsevierStyleSup">&#174;</span>&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">They are the most commonly used anticoagulants and have the advantage of oral administration&#44; ability to measure the effectiveness of the drug using the International Normalised Ratio &#40;INR&#41; and availability of a reversal agent&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The level of anticoagulation reached using these agents&#44; measured using the INR&#44; is linked to the worst outcomes in patients who have suffered a brain bleed&#46; This means that as the level of anticoagulation increases&#44; the likelihood of morbidity and mortality also increases&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> Any patient arriving in the emergency department with a cerebral haemorrhagic injury requires an INR test to determine the course of treatment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Recommendations&#58; We strongly recommend stopping and reversing coumarin anticoagulants in all patients affected by cerebral or spinal haemorrhage&#44; regardless of the degree of INR elevation&#44; size of the haemorrhage or its location&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">6&#44;7</span></a> Reversal of anticoagulation within 2<span class="elsevierStyleHsp" style=""></span>h of arrival may reduce mortality rates by 38&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Options&#58;</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Fresh frozen plasma&#58; This contains clotting factors that are useful for treating acute haemorrhage associated with coumarin anticoagulants&#46; It is important to consider that the time required to match the patient&#39;s blood type to the plasma and thaw the sample may delay plasma administration&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> The most widely recommended dosage in the literature is between 10 and 15<span class="elsevierStyleHsp" style=""></span>ml of plasma per kg of body weight and&#44; therefore&#44; the usual volume varies between 180 and 400<span class="elsevierStyleHsp" style=""></span>ml&#46; Special care should be taken in patients with heart failure receiving large volumes of plasma as they are particularly at risk of developing severe pulmonary oedema&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#46;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Vitamin K&#58; This is useful for treating coumarin-induced haemorrhage&#44; but it is important to take into account that it is not able to fully normalise INR values when used as a single agent&#46; The response to vitamin K is much slower than the response to fresh frozen plasma&#44; requiring at least 2&#8211;6<span class="elsevierStyleHsp" style=""></span>h&#44; although the effect is more commonly noticeable after 24<span class="elsevierStyleHsp" style=""></span>h&#46; Concomitant use with other drugs is effective for preventing rebound INR increase once INR has been corrected using other means&#46; Although it can be administered in various ways&#44; intravenous administration is the most effective in acute patients&#46; The standard dosage is 10<span class="elsevierStyleHsp" style=""></span>mg administered over 30<span class="elsevierStyleHsp" style=""></span>min to prevent an anaphylactic reaction&#44; which is a common side effect of rapid infusion&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Prothrombin complex concentrates&#58; In comparison to fresh frozen plasma&#44; these have less adverse effects and provide significantly faster reversal of anticoagulation&#44; as it has been proven that an INR below 1&#46;3 can be achieved in 69&#37; of patients within 1<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">11&#44;12</span></a> Moreover&#44; they can be administered more rapidly than fresh frozen plasma since they do not need to be cross-matched or thawed before use and do not require the administration of large volumes&#44; thus decreasing the risk of pulmonary oedema&#46; It is important to consider that prothrombin complex concentrate solutions contain a small amount of heparin and are therefore contraindicated in patients who have previously had heparin-induced thrombocytopaenia&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> The recommended dosage is 25&#8211;30<span class="elsevierStyleHsp" style=""></span>IU&#47;kg for prothrombin complex concentrate &#40;Beriplex<span class="elsevierStyleSup">&#174;</span>&#44; Prothromplex<span class="elsevierStyleSup">&#174;</span>&#44; Octoplex<span class="elsevierStyleSup">&#174;</span>&#41; and 50&#8211;100<span class="elsevierStyleHsp" style=""></span>IU&#47;kg for activated prothrombin complex concentrate &#40;Feiba<span class="elsevierStyleSup">&#174;</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">14&#44;15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Recombinant factor VIIa &#40;rFVIIa&#41; &#40;Novoseven<span class="elsevierStyleSup">&#174;</span>&#41;&#58; Initially used in patients with haemophilia&#44; rFVIIa is becoming increasingly popular given that it is a fast-acting agent with less potential for volume overload and poses no risk of pathogen transmission&#46; In the context of patients treated with coumarin anticoagulants&#44; the efficacy and safety of rFVIIa in quickly lowering INR to normal levels has been demonstrated&#46; A lower dose is also required than the dose expected for haemophilic patients&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a> Duration of INR correction depends on the dose of rFVIIa administered&#59; a continuous infusion may be used if required&#46; The recommended dose is 80<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg to normalise INR over a period of more than 6<span class="elsevierStyleHsp" style=""></span>h&#46; Unfortunately&#44; there are disadvantages related to using rFVIIa since it is associated with a higher risk of arterial thrombosis and it is much more expensive than the other treatments described above&#46; Therefore&#44; its current use is limited to the presence of active bleeding that cannot be controlled using the other measures described or to patients who do not agree to receiving blood products&#44; as is the case of Jehova&#39;s Witnesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">17&#8211;19</span></a></p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Direct oral anticoagulants&#58; dabigatran &#40;Pradaxa<span class="elsevierStyleSup">&#174;</span>&#41;&#44; rivaroxaban &#40;Xarelto<span class="elsevierStyleSup">&#174;</span>&#41;&#44; edoxaban &#40;Lixiana<span class="elsevierStyleSup">&#174;</span>&#41; and apixaban &#40;Eliquis<span class="elsevierStyleSup">&#174;</span>&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Currently&#44; there is one direct thrombin inhibitor &#40;dabigatran&#41; and 3 direct factor Xa inhibitors &#40;rivaroxaban&#44; apixaban and edoxaban&#41; with approved indications for prophylaxis and antithrombotic treatment in different situations&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Dabigatran&#46; In emergency situations&#44; the presence or absence of anticoagulation due to dabigatran can be determined by testing activated partial thromboplastin time &#40;aPTT&#41; and thrombin time&#46; Although aPTT<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>s is indicative of the absence of anticoagulant activity and aPTT<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>s is associated with an increased risk of bleeding&#44; there is no linear relationship between aPTT and the patient&#39;s level of anticoagulation&#46; There is&#44; however&#44; a linear relationship between aPTT and ecarin clotting time&#44; but this test is not available at many centres&#46; If emergency reversal is required&#44; there is a specific antidote&#44; idarucizumab &#40;Praxbind<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The recommended dose is 5<span class="elsevierStyleHsp" style=""></span>g of idarucizumab &#40;2<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;50<span class="elsevierStyleHsp" style=""></span>ml vials&#41; by intravenous administration as 2 consecutive infusions over 5&#8211;10<span class="elsevierStyleHsp" style=""></span>min each or as a bolus injection&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> Administration of a second 5-g dose of idarucizumab may be considered if clotting times are still prolonged and there is still a clinical need to rapidly reverse the anticoagulant effect&#46; Its absorption is relatively fast&#46; Therefore&#44; if the drug was taken within the previous 2<span class="elsevierStyleHsp" style=""></span>h&#44; gastric lavage and administration of activated charcoal suspension may be effective&#46; Because of its low plasma protein binding &#40;approximately 3&#37;&#41;&#44; haemodialysis may remove sufficient drug from the bloodstream&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Direct factor Xa inhibitors &#40;rivaroxaban&#44; apixaban and edoxaban&#41;&#46; The effect of these drugs may be deduced using thrombin time&#44; but the technique of choice for monitoring them is the anti-Xa assay&#46; No antidotes are available for clinical use&#44; although 2 drugs that reverse the action of direct factor Xa inhibitors are being studied&#58; andexanet alpha and ciraparantag&#46; However&#44; since clinical experience with these compounds is very limited&#44; personalised treatment of each case in cooperation with the haemostasis departments at each centre is recommended&#46; If emergency correction is required&#44; the standard procedure is to use activated prothrombin complex concentrate &#40;80<span class="elsevierStyleHsp" style=""></span>IU&#47;kg&#41; or even rFVIIa &#40;80<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg&#41;&#46; Gastric lavage associated with the administration of activated charcoal may be useful for up to 4<span class="elsevierStyleHsp" style=""></span>h after ingestion in the case of rivaroxaban and apixaban and for up to 2<span class="elsevierStyleHsp" style=""></span>h in the case of edoxaban&#46; Plasma protein binding varies depending on the drug&#44; making haemodialysis ineffective for rivaroxaban and apixaban &#40;plasma protein binding higher than 90&#37;&#41; and only partially effective for edoxaban &#40;plasma protein binding of 50&#37;&#41;&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Restarting anticoagulant therapy</span><p id="par0085" class="elsevierStylePara elsevierViewall">Available data are inadequate for determining the optimal time to restart anticoagulation following cerebral or spinal haemorrhage&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The first step is thrombotic risk stratification&#44; for which the classification recommended in the evidence-based clinical practice guidelines published by the American College of Chest Physicians in 2012 &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a> is very useful&#46; In the case of atrial fibrillation&#44; use of the CHADS2 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a> or CHA2DS2-VASC &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> score is recommended&#46; The latter is preferable in patients with low or moderate risk of thromboembolic events&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Without a doubt&#44; the group with the most complex patients are those categorised as being at high thrombotic risk&#44; particularly if their INR has been corrected using prothrombin complex concentrates or rFVIIa&#46; We recommend starting these patients on low loses of low-molecular-weight heparin &#40;LMWH&#41; 48<span class="elsevierStyleHsp" style=""></span>h after surgery as prophylaxis for deep vein thrombosis &#40;DVT&#41;&#46; Anticoagulant therapy may be restarted completely within 7&#8211;14 days&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">4&#44;25&#44;26</span></a> if the other specialists involved in the patient&#39;s care agree&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">As DVT prophylaxis during the immediate post-operative period&#44; the use of pneumatic compression stockings and ambulation as early as possible is recommended for all other patients&#46; The ideal time for restarting anticoagulation should be assessed on an individual basis&#44; based primarily on the reason why anticoagulant therapy was prescribed and the cause of bleeding&#46; In most patients&#44; it is not necessary to restart anticoagulant therapy within the first 2 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#44;13</span></a></p></span></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Standard protocol for cerebral or spinal haemorrhage in patients receiving antiplatelet therapy</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Cyclooxygenase inhibitors&#58; acetylsalicylic acid</span><p id="par0105" class="elsevierStylePara elsevierViewall">Both cyclooxygenase isoforms&#44; COX-1 and COX-2&#44; are inhibited irreversibly by acetylsalicylic acid &#40;ASA&#41;&#44; inhibiting platelet function&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In those patients with haemorrhage requiring neurosurgical treatment&#44; platelet transfusions are recommended&#46; In those patients with haemorrhage&#44; but who are not candidates for surgery&#44; a single dose of desmopressin &#40;0&#46;4 mcg&#47;kg IV&#41; should be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">7&#44;27</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">ADP receptor inhibitors&#58; clopidogrel</span><p id="par0115" class="elsevierStylePara elsevierViewall">Like ASA&#44; the effect of clopidogrel continues until new platelets are generated&#44; which is why platelet transfusions are recommended in those patients with haemorrhage requiring neurosurgical treatment&#46; In those patients with haemorrhage&#44; but who are not candidates for surgery&#44; a single 0&#46;4<span class="elsevierStyleHsp" style=""></span>mcg&#47;kg IV dose of desmopressin will be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">9&#44;28</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Restarting antiplatelet therapy</span><p id="par0120" class="elsevierStylePara elsevierViewall">Antiplatelet therapy should only be restarted in patients at high risk for atherothrombosis &#40;atrial fibrillation&#44; cardiomyopathy&#44; stenosis of large intra&#47;extracranial vessels&#41;&#46; If no concomitant heart disease is present&#44; restarting such therapy for hypertension&#44; diabetes mellitus or dyslipidaemia is not justified&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Likewise&#44; antiplatelet therapy in combination with anticoagulants increases the risk of bleeding&#44; and is therefore assumed to increase the risk of recurrent cerebral haemorrhage&#46; Antiplatelet drugs &#40;including low-dose ASA&#41; should be avoided in patients restarting anticoagulation therapy following cerebral haemorrhage&#46; In this situation&#44; if the use of such drugs cannot be avoided&#44; the dose required to achieve the lowest effective INR possible &#40;1&#46;8&#8211;2&#46;5 in atrial fibrillation&#41; is recommended before restarting therapy and INR and blood pressure should be closely monitored&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Perioperative procedure in patients receiving antithrombotic therapy who are going to undergo cranial or spinal surgery</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Thromboembolic risk stratification for patients receiving anticoagulants</span><p id="par0130" class="elsevierStylePara elsevierViewall">As discussed above&#44; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the risk stratification for the development of perioperative thromboembolic complications in patients receiving anticoagulant therapy depending on why anticoagulation was prescribed &#40;mechanical heart valve&#44; atrial fibrillation or venous thromboembolism&#41; and patient-specific characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Thromboembolic risk stratification for patients receiving antiplatelet therapy</span><p id="par0135" class="elsevierStylePara elsevierViewall">The thrombotic risk stratification for patients treated with antiplatelet therapy is shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; The most controversial group is the group of patients with stents &#40;primarily coronary stents&#44; although the considerations outlined for such stents can be expanded to include carotid stents&#44; intracranial flow diverters or aortic endoprosthesis&#41; since such patients are often treated with dual antiplatelet therapy and require individualised assessment to establish the true thromboembolic risk&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">From the cardiac point of view&#44; for asymptomatic patients with coronary stents&#44; thromboembolic risk secondary to discontinuation of dual antiplatelet therapy depends on&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Why the stent was implanted&#58; the thromboembolic risk is greater in patients requiring the implant as a result of an acute coronary syndrome than when the procedure is elective&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Type of stent and time since placement&#58; drug-eluting stents seem to have a similar risk to bare-metal stents&#44; but require dual antiplatelet therapy to continue for longer due to delayed endothelialisation&#46; Although this difference appears to be less noticeable with second-generation drug-eluting stents&#44; the rule is that dual antiplatelet therapy should be continued for a minimum of 12 months with drug-eluting stents and 6 months with bare-metal stents&#46; However&#44; every effort should be made to continue dual antiplatelet therapy for the first 30 days after the procedure&#46; Therefore&#44; elective surgery should be postponed if possible&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Classification of elective invasive procedures according to bleeding risk</span><p id="par0155" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows the bleeding risk stratification of different elective invasive procedures&#46; However&#44; although the bleeding risk of neurosurgical procedures is generally considered to be high&#44; this bleeding risk is not identical for all patients and varies according to the type of procedure performed &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; In general&#44; this stratification can be summarised as follows&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Any intradural approach is considered HIGH RISK&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Any intracranial approach is considered HIGH RISK&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Any intraspinal approach is considered HIGH RISK&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Treatments related to peripheral nerve decompression are considered INTERMEDIATE RISK&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Peripheral nerve and muscle biopsies are considered LOW RISK&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Perioperative procedure in patients receiving antiplatelet therapy</span><p id="par0185" class="elsevierStylePara elsevierViewall">The recommended time for discontinuation of antiplatelet therapy for elective neurosurgery is 7 days for clopidogrel and 5 days for ASA&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In the case of semi-urgent surgery &#40;e&#46;g&#46; elective brain tumour surgery&#41;&#44; antiplatelet therapy will be discontinued for the minimum time required to ensure adequate surgical haemostasis&#44; considering the patient&#39;s thrombotic risk and the procedure&#39;s bleeding risk&#46; For example&#44; in the case of ASA&#44; a short 2-day interval or a long 5-day interval will be selected according to the thrombotic&#47;bleeding risk&#46; Platelet function tests may help determine when primary haemostasis is adequate in order to allow cranial or spinal surgery&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">When a patient is receiving antiplatelet therapy due to having a coronary stent and surgery needs to be performed during periods of maximum risk &#40;within 6 months for bare-metal stents and 12 months for drug-eluting stents&#41;&#44; it is recommended that the surgery be delayed&#44; if possible&#44; and the patient be informed of potential risks&#46; If&#44; in the end&#44; the surgery needs to go ahead&#44; the patient&#39;s cardiologist should be consulted in order to maintain the minimum antiplatelet therapy necessary during the perioperative period or replacement therapy with parenteral antiplatelet drugs should be assessed&#46; It is important to consider that thromboembolism tends to occur within 7&#8211;10 days of discontinuing antiplatelet therapy&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">For those patients receiving dual antiplatelet therapy or ASA alone at doses higher than 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day or other drugs &#40;triflusal&#44; cilostazol&#44; clopidogrel&#44; prasugrel or ticagrelor&#41;&#44; treatment must be replaced by ASA at a dose of 100<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; provided that discontinuation of antiplatelet therapy is not recommended&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Restarting antiplatelet therapy during the postoperative period</span><p id="par0205" class="elsevierStylePara elsevierViewall">It is recommended that antiplatelet therapy be restarted 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h after surgery when haemostasis is adequate and provided that haemorrhagic complications have been ruled out&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Perioperative procedure in patients receiving anticoagulants&#46; Guidelines for stopping and restarting anticoagulants during the perioperative period</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Coumarin-derived anticoagulants&#58; acenocoumarol &#40;Sintrom<span class="elsevierStyleSup">&#174;</span>&#41; and warfarin &#40;Aldocoumar<span class="elsevierStyleSup">&#174;</span>&#41;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Acenocoumarol and warfarin should be stopped 4 and 5 days before surgery&#44; respectively&#44; and the patient should start enoxaparin at therapeutic doses &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg every 12<span class="elsevierStyleHsp" style=""></span>h if creatinine clearance is &#62;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41; 24&#8211;36<span class="elsevierStyleHsp" style=""></span>h after stopping acenocoumarol or warfarin&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">30&#44;31</span></a> The final dose &#40;half the usual daily dose&#41; should be administered 24<span class="elsevierStyleHsp" style=""></span>h before surgery&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The evening before the surgery&#44; in addition to not taking enoxaparin&#44; haemostatic screening tests&#44; including prothrombin time&#44; are recommended&#46; Preoperative management should not change if INR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#44; but vitamin K should be administered if INR is any higher&#46; The INR should be re-checked on the morning of the surgery and the surgery should be postponed if INR is still above 1&#46;2 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Direct oral anticoagulants&#58; dabigatran &#40;Pradaxa<span class="elsevierStyleSup">&#174;</span>&#41;&#44; rivaroxaban &#40;Xarelto<span class="elsevierStyleSup">&#174;</span>&#41;&#44; edoxaban &#40;Lixiana<span class="elsevierStyleSup">&#174;</span>&#41; and apixaban &#40;Eliquis<span class="elsevierStyleSup">&#174;</span>&#41;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Perioperative management of direct oral anticoagulants is described in the SmPC of these medicinal products&#46; Nevertheless&#44; given the limited evidence available&#44; and the even more limited experience with these drugs&#44; careful use during the perioperative period is recommended&#46; Different clinical practice guidelines&#44; expert recommendations and reviews generally recommend discontinuing drugs 1&#8211;5 days prior to surgery&#44; depending on the specific drug used&#44; renal function&#44; bleeding risk of the surgery and thrombotic risk associated with discontinuation of anticoagulant therapy&#46; Bridging therapy with LMWH is not usually considered&#44; even in patients at high thrombotic risk&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">However&#44; in the event of surgery posing a high risk of bleeding or haemorrhagic complications during the postoperative period&#44; administration of LMWH is recommended for postoperative management of these patients before restarting oral anticoagulants&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">32</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a> gives guidelines for stopping direct oral anticoagulants during the perioperative period&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Perioperative procedure for patients with no prior antithrombotic therapy who are going to undergo neurosurgery</span><p id="par0235" class="elsevierStylePara elsevierViewall">To prevent DVT&#44; the use of intermittent pneumatic compression stockings is recommended from the start of surgery&#44; with these being removed once the patient begins to walk&#46; From day 2 of the postoperative period&#44; and once haemorrhagic complications have been ruled out&#44; the use of low doses of LMWH or unfractionated heparin is recommended in patients at high risk of DVT&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In the event of DVT or pulmonary thromboembolism&#44; the use of heparin or LMWH at doses resulting in anticoagulation is recommended once haemorrhagic complications have been ruled out&#44; followed by oral anticoagulants at low doses &#40;INR 2&#41; for 3 months&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0245" class="elsevierStylePara elsevierViewall">We declare that there was no source of funding to carry out this protocol&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:3 [
          "identificador" => "xres949037"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec921145"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres949038"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec921146"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Standard protocol for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy"
          "secciones" => array:1 [
            0 => array:3 [
              "identificador" => "sec0015"
              "titulo" => "Standard protocol for cerebral or spinal haemorrhage in patients receiving anticoagulant therapy"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0020"
                  "titulo" => "Proposed consensus protocol"
                ]
                1 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Coumarin-derived anticoagulants&#58; acenocoumarol &#40;Sintrom&#41; and warfarin &#40;Aldocoumar&#41;"
                ]
                2 => array:2 [
                  "identificador" => "sec0030"
                  "titulo" => "Direct oral anticoagulants&#58; dabigatran &#40;Pradaxa&#41;&#44; rivaroxaban &#40;Xarelto&#41;&#44; edoxaban &#40;Lixiana&#41; and apixaban &#40;Eliquis&#41;"
                ]
                3 => array:2 [
                  "identificador" => "sec0035"
                  "titulo" => "Restarting anticoagulant therapy"
                ]
              ]
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Standard protocol for cerebral or spinal haemorrhage in patients receiving antiplatelet therapy"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Cyclooxygenase inhibitors&#58; acetylsalicylic acid"
            ]
            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "ADP receptor inhibitors&#58; clopidogrel"
            ]
            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Restarting antiplatelet therapy"
            ]
            3 => array:3 [
              "identificador" => "sec0060"
              "titulo" => "Perioperative procedure in patients receiving antithrombotic therapy who are going to undergo cranial or spinal surgery"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0065"
                  "titulo" => "Thromboembolic risk stratification for patients receiving anticoagulants"
                ]
                1 => array:2 [
                  "identificador" => "sec0070"
                  "titulo" => "Thromboembolic risk stratification for patients receiving antiplatelet therapy"
                ]
                2 => array:2 [
                  "identificador" => "sec0075"
                  "titulo" => "Classification of elective invasive procedures according to bleeding risk"
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "sec0080"
              "titulo" => "Perioperative procedure in patients receiving antiplatelet therapy"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Restarting antiplatelet therapy during the postoperative period"
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "sec0090"
              "titulo" => "Perioperative procedure in patients receiving anticoagulants&#46; Guidelines for stopping and restarting anticoagulants during the perioperative period"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Coumarin-derived anticoagulants&#58; acenocoumarol &#40;Sintrom&#41; and warfarin &#40;Aldocoumar&#41;"
                ]
                1 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Direct oral anticoagulants&#58; dabigatran &#40;Pradaxa&#41;&#44; rivaroxaban &#40;Xarelto&#41;&#44; edoxaban &#40;Lixiana&#41; and apixaban &#40;Eliquis&#41;"
                ]
              ]
            ]
            6 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Perioperative procedure for patients with no prior antithrombotic therapy who are going to undergo neurosurgery"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0110"
          "titulo" => "Funding"
        ]
        8 => array:2 [
          "identificador" => "sec0115"
          "titulo" => "Conflicts of interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-07-25"
    "fechaAceptado" => "2017-08-06"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec921145"
          "palabras" => array:6 [
            0 => "Antithrombotic treatment"
            1 => "Anticoagulant therapy"
            2 => "Antiplatelet therapy"
            3 => "Haemorrhage risk"
            4 => "Perioperative"
            5 => "Neurosurgery"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec921146"
          "palabras" => array:6 [
            0 => "Tratamiento antitromb&#243;tico"
            1 => "Anticoagulantes"
            2 => "Antiagregantes"
            3 => "Riesgo hemorragico"
            4 => "Perioperatorio"
            5 => "Neurocirugia"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The use of antithrombotic medication &#40;antiplatelet and&#47;or anticoagulant therapy&#41; is widespread&#46; Currently&#44; the management of neurosurgical patients receiving this type of therapy continues to be a problem of special importance&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients receiving antithrombotic treatment may need neurosurgical care because of bleeding secondary to such treatment&#44; non-haemorrhagic neurosurgical lesions requiring urgent attention&#44; or simply elective neurosurgical procedures&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In addition&#44; the consequences of reintroducing early &#40;bleeding or rebleeding&#41; or late &#40;thrombotic or thromboembolic&#41; anticoagulation can be devastating&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In this paper we present the antithrombotic treatment consensus protocol during the perioperative and periprocedural period&#44; both in emergent surgery and in elective neurosurgical procedures&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El uso de medicaci&#243;n antitromb&#243;tica &#40;antiagregante y&#47;o anticoagulante&#41; se encuentra ampliamente extendido&#46; El manejo de los pacientes neuroquir&#250;rgicos que reciben este tipo de terapia contin&#250;a siendo&#44; a d&#237;a de hoy&#44; un problema de especial importancia&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los pacientes en tratamiento antitromb&#243;tico pueden necesitar atenci&#243;n neuroquir&#250;rgica bien por presentar sangrados secundarios a dicho tratamiento&#44; lesiones neuroquir&#250;rgicas no hemorr&#225;gicas pero que precisen intervenci&#243;n urgente&#44; o simplemente procedimientos neuroquir&#250;rgicos electivos&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Adem&#225;s&#44; las consecuencias de la reintroducci&#243;n de la anticoagulaci&#243;n temprana &#40;sangrado o resangrado&#41; o tard&#237;a &#40;tromb&#243;ticas o tromboemb&#243;licas&#41; pueden ser devastadoras&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En este documento presentamos el protocolo de consenso en el tratamiento antitromb&#243;tico durante el periodo perioperatorio y periprocedimiento&#44; tanto en cirug&#237;a emergente como en procedimientos electivos de neurocirug&#237;a&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Arikan Abell&#243; F&#44; Ley Urzaiz L&#44; Fern&#225;ndez Al&#233;n J&#44; Mart&#237;n L&#225;ez R&#44; Grupo de Trabajo de Patolog&#237;a Vascular de la Sociedad Espa&#241;ola de Neurocirug&#237;a&#46; Protocolo de consenso en el tratamiento antitromb&#243;tico &#40;anticoagulaci&#243;n y antiagregaci&#243;n&#41; durante el periodo perioperatorio y periprocedimiento en neurocirug&#237;a&#46; Neurocirug&#237;a&#46; 2017&#59;28&#58;284&#8211;293&#46;</p>"
      ]
    ]
    "multimedia" => array:9 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1505
            "Ancho" => 2667
            "Tamanyo" => 350412
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Proposed algorithm for cerebral or spinal haemorrhage in patients receiving antithrombotic therapy&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1579
            "Ancho" => 2167
            "Tamanyo" => 206100
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Perioperative procedure for patients treated with coumarin-derived anticoagulants&#58; acenocoumarol &#40;Sintrom<span class="elsevierStyleSup">&#174;</span>&#41;&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; AT&#58; antithrombin&#59; CHADS2&#58; score for estimating stroke risk in patients with atrial fibrillation&#59; CHA2DS2-VASC&#58; modification of CHADS2 score by including additional stroke risk modifiers&#59; HTN&#58; hypertension&#59; PC&#58; protein C&#59; PS&#58; protein S&#59; TIA&#58; transient ischaemic attack&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">High risk of thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate risk of thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Low risk of thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mechanical heart valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Any mitral valve prosthesis<br>&#8226; Any caged-ball or tilting-disc aortic valve prosthesis<br>&#8226; Recent &#40;&#60;6 months&#41; stroke or TIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Bileaflet aortic valve prosthesis and one or more of the following risk factors for stroke&#58; AF&#44; prior stroke or TIA&#44; HTN&#44; diabetes mellitus&#44; heart failure&#44; age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>75 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Bileaflet aortic valve without AF and no other risk factors for stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; CHADS2<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3 &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#59; CHA2DS2-VASC<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>6 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;<br>&#8226; Recent &#40;&#60;3 months&#41; stroke or TIA<br>&#8226; Valvular rheumatic heart disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; CHADS2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#8211;2&#59; CHA2DS2-VASC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#8211;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; CHADS2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0 and no prior stroke or TIA&#59; CHA2DS2-VASC<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#8211;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Venous thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Recent &#40;&#60;3 months&#41; venous thromboembolism<br>&#8226; Severe thrombophilia &#40;deficiency of PC&#44; PS or AT&#59; antiphospholipid syndrome or multiple abnormalities&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Prior &#40;3&#8211;12 months&#41; venous thromboembolism<br>&#8226; Non-severe thrombophilia&#58; heterozygous factor V Leiden&#44; heterozygous prothrombin G20210A mutation or other states &#40;elderly&#44; high body mass index&#44; chronic diseases or presence of antiphospholipid antibodies&#41;<br>&#8226; Recurrent episodes of venous thromboembolism and prior episodes following surgery<br>&#8226; Active cancer &#40;treated within the last 6 months or in palliative care&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Single venous thromboembolism<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>12 months prior and no other risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607232.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Thrombotic risk stratification for patients treated with oral anticoagulants&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Stroke risk according to CHADS2 score expressed as &#37; &#40;95&#37; CI&#41;&#58; 0 points&#58; 1&#46;9 &#40;1&#46;2&#8211;3&#41;&#59; 1 point&#58; 2&#46;8 &#40;2&#8211;3&#46;8&#41;&#59; 2 points&#58; 4 &#40;3&#46;1&#8211;5&#46;1&#41;&#59; 3 points&#58; 5&#46;9 &#40;4&#46;6&#8211;7&#46;3&#41;&#59; 4 points&#58; 8&#46;5 &#40;6&#46;3&#8211;11&#46;1&#41;&#59; 5 points&#58; 12&#46;5 &#40;8&#46;2&#8211;17&#46;5&#41;&#59; 6 points&#58; 18&#46;2 &#40;10&#46;5&#8211;27&#46;4&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Condition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#58; blood pressure consistently above 140&#47;90<span class="elsevierStyleHsp" style=""></span>mmHg &#40;or hypertension treated with medication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Age &#8805; 75 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">S2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prior stroke&#44; transient ischaemic attack or thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607236.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">CHADS2 score&#46; Predictive score for estimating stroke risk in patients with atrial fibrillation&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Stroke risk according to CHA2DS2-VASC score expressed as &#37;&#58; 0 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#37;&#59; 1 point<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;3&#37;&#59; 2 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;2&#37;&#59; 3 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;2&#37;&#59; 4 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#37;&#59; 5 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#46;7&#37;&#59; 6 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;6&#37;&#59; 7 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#46;8&#37;&#59; 8 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;5&#37;&#59; 9 points<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#46;2&#37;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Condition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Congestive heart failure or &#40;left ventricular systolic dysfunction&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">H&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertension&#58; blood pressure consistently above 140&#47;90<span class="elsevierStyleHsp" style=""></span>mmHg &#40;or hypertension treated with medication&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Age<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>75 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">S2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prior stroke&#44; transient ischaemic attack or thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vascular disease &#40;e&#46;g&#46; peripheral arterial disease&#44; myocardial infarction&#44; aortic atheroma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Age<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>65&#8211;74 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607235.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">CHA2DS2-VASC&#46; To complement the CHADS2 score with other stroke risk factors&#44; the CHA2DS2-VASC score was proposed&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">High thrombotic risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Moderate thrombotic risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Low thrombotic risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Patients with bare-metal stent &#40;&#60;6 weeks&#41; or drug-eluting stent &#40;&#60;12 months&#41;<br>&#8226; Acute myocardial infarction or ischaemic stroke &#40;&#60;3 months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Patients with bare-metal stent &#40;&#62;6 weeks&#41; or drug-eluting stent &#40;&#62;12 months&#41;<br>&#8226; Secondary prevention of acute myocardial infarction or ischaemic stroke&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Primary prevention of cardiovascular disease and diabetes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607237.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Thrombotic risk stratification for patients treated with antiplatelet drugs&#46;</p>"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery that does not necessarily require anticoagulation to be stopped&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery with a low risk of bleeding &#40;uncommon or with low clinical impact&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery with a high risk of bleeding &#40;common or with high clinical impact&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Single or multiple dental surgeries including alveolectomy and implant placement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Major thoracic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Coronary artery bypass graft surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cataract and glaucoma surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Major orthopaedic surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heart surgery with valve replacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coronary angiography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intra-abdominal surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Major vascular surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dermatological surgeries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pacemaker implantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neurosurgical procedures<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laparoscopic cholecystectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prostatectomy or bladder surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hernia surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Major cancer surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colon polypectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Any major surgery lasting &#62;45<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607234.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Haemorrhagic risk in neurosurgical procedures is generally considered to be high&#44; but it is not identical in all patients&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Bleeding risk stratification of different elective invasive procedures&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at6"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Bleeding risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adequate haemostasis<br>Possible bleeding is not a critical risk for the patient and does not affect surgery outcome<br>Transfusions not required&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minor surgery under local anaesthesia&#58;<br>&#8226; Muscle biopsy<br>&#8226; Peripheral nerve biopsy<br>&#8226; Surgical wound check-up<br>&#8226; Cerebral angiography<br>&#8226; Percutaneous spine procedures&#58; facet fusion and rhizolysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Complicated surgical haemostasis<br>Possible bleeding is not a critical risk for the patient and does not affect surgery outcome<br>Bleeding increases the need for transfusion or repeat surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minimally invasive procedures&#58;<br>&#8226; Carotid stent<br>&#8226; Peripheral nerve decompression<br>&#8226; Percutaneous approach to treat the trigeminal nerve<br>&#8226; Kyphoplasty&#47;vertebroplasty<br>&#8226; Lumbar puncture<br>&#8226; Percutaneous spine procedures&#58; epidural&#44; transforaminal and caudal<br>&#8226; Percutaneous spine instrumentation without access to the spinal canal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perioperative bleeding could have an impact on the patient&#39;s life or surgery outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Invasive procedures&#58;<br>&#8226; Craniotomy&#47;craniectomy<br>&#8226; Brain or spinal cord biopsies<br>&#8226; Complex spine surgery or with access to the spinal canal &#40;laminectomy&#44; discectomy&#44; deformity correction&#44; etc&#46;&#41;<br>&#8226; Carotid endarterectomy<br>&#8226; Embolisation &#40;intracranial&#47;spinal cord&#41;<br>&#8226; Mechanical embolectomy<br>&#8226; Deep brain stimulation&#44; deep brain electrodes<br>&#8226; CSF shunts &#40;ventriculoperitoneal shunt&#44; ventriculoatrial shunt&#44; lumbar-peritoneal shunt&#44; continuous lumbar drainage and external ventricular drainage&#41;<br>&#8226; Endoscopic transsphenoidal and skull base surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607233.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Bleeding risk stratification of neurosurgical procedures&#46;</p>"
        ]
      ]
      8 => array:8 [
        "identificador" => "tbl0035"
        "etiqueta" => "Table 7"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at7"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bleeding risk</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Dabigatran</td><td class="td" title="table-entry  " align="left" valign="top">GFR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Continue with anticoagulation&#44; avoiding surgery during the peak action time &#40;2<span class="elsevierStyleHsp" style=""></span>h after ingestion&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rivaroxaban Apixaban&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GFR<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1607231.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Guidelines for stopping direct oral anticoagulants based on the compound used&#44; glomerular filtration and bleeding risk&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:32 [
            0 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Agencia Espa&#241;ola de Medicamentos y Productos Sanitarios&#46; Utilizaci&#243;n de antiagregantes y anticoagulantes en Espa&#241;a &#40;1992&#8211;2006&#41;&#46; Available from&#58; <a href="http://cima.aemps.es/medicamentosUsoHumano/observatorio/docs/antiagregantes.pdf">http&#58;&#47;&#47;cima&#46;aemps&#46;es&#47;medicamentosUsoHumano&#47;observatorio&#47;docs&#47;antiagregantes&#46;pdf</a> &#91;accessed 17&#46;06&#46;17&#93;&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "1300&#8211;1305 e1302"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "National trends in ambulatory oral anticoagulant use"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "G&#46;D&#46; Barnes"
                            1 => "E&#46; Lucas"
                            2 => "G&#46;C&#46; Alexander"
                            3 => "Z&#46;D&#46; Goldberger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2015"
                        "volumen" => "128"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Prevalence of oral anticoagulation and quality of its management in primary healthcare&#58; a study by the Health Sentinel Network of the Region of Valencia &#40;Spain&#41;&#93;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Boned-Ombuena"
                            1 => "J&#46; Perez-Panades"
                            2 => "A&#46; Lopez-Maside"
                            3 => "M&#46; Miralles-Espi"
                            4 => "S&#46; Guardiola Vilarroig"
                            5 => "D&#46; Adam Ruiz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Aten Primaria"
                        "fecha" => "2017"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0180"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of anticoagulation following central nervous system hemorrhage in patients with high thromboembolic risk"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46;W&#46; Hawryluk"
                            1 => "J&#46;W&#46; Austin"
                            2 => "J&#46;C&#46; Furlan"
                            3 => "J&#46;B&#46; Lee"
                            4 => "C&#46; O&#8217;Kelly"
                            5 => "M&#46;G&#46; Fehlings"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1538-7836.2010.03882.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thromb Haemost"
                        "fecha" => "2010"
                        "volumen" => "8"
                        "paginaInicial" => "1500"
                        "paginaFinal" => "1508"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20403088"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0185"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Degree of anticoagulation&#44; but not warfarin use itself&#44; predicts adverse outcomes after traumatic brain injury in elderly trauma patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46;M&#46; Pieracci"
                            1 => "S&#46;R&#46; Eachempati"
                            2 => "J&#46; Shou"
                            3 => "L&#46;J&#46; Hydo"
                            4 => "Barie PS&#58;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/TA.0b013e31812e5216"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2007"
                        "volumen" => "63"
                        "paginaInicial" => "525"
                        "paginaFinal" => "530"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18073596"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0190"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pharmacology and management of the vitamin K antagonists&#58; American College of Chest Physicians Evidence-Based Clinical Practice Guidelines &#40;8th ed&#46;&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Ansell"
                            1 => "J&#46; Hirsh"
                            2 => "E&#46; Hylek"
                            3 => "A&#46; Jacobson"
                            4 => "M&#46; Crowther"
                            5 => "G&#46; Palareti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.08-0670"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2008"
                        "volumen" => "133"
                        "paginaInicial" => "160S"
                        "paginaFinal" => "198S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18574265"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0195"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guideline for eeversal of antithrombotics in intracranial hemorrhage&#58; a statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;A&#46; Frontera"
                            1 => "J&#46;J&#46; Lewin 3rd"
                            2 => "A&#46;A&#46; Rabinstein"
                            3 => "I&#46;P&#46; Aisiku"
                            4 => "A&#46;W&#46; Alexandrov"
                            5 => "A&#46;M&#46; Cook"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12028-015-0222-x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurocrit Care"
                        "fecha" => "2016"
                        "volumen" => "24"
                        "paginaInicial" => "6"
                        "paginaFinal" => "46"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26714677"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "&#91;discusi&#243;n 1137-1139&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46;A&#46; Ivascu"
                            1 => "G&#46;A&#46; Howells"
                            2 => "F&#46;S&#46; Junn"
                            3 => "H&#46;A&#46; Bair"
                            4 => "P&#46;J&#46; Bendick"
                            5 => "R&#46;J&#46; Janczyk"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "2005"
                        "volumen" => "59"
                        "paginaInicial" => "1131"
                        "paginaFinal" => "1137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16385291"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Emergency reversal of anticoagulation and antiplatelet therapies in neurosurgical patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;E&#46; Beshay"
                            1 => "H&#46; Morgan"
                            2 => "C&#46; Madden"
                            3 => "W&#46; Yu"
                            4 => "R&#46; Sarode"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/2009.7.JNS0982"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "2010"
                        "volumen" => "112"
                        "paginaInicial" => "307"
                        "paginaFinal" => "318"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19663548"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intracerebral hemorrhage associated with oral anticoagulant therapy&#58; current practices and unresolved questions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46; Steiner"
                            1 => "J&#46; Rosand"
                            2 => "M&#46; Diringer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/01.STR.0000196989.09900.f8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Stroke"
                        "fecha" => "2006"
                        "volumen" => "37"
                        "paginaInicial" => "256"
                        "paginaFinal" => "262"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16339459"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcomes of urgent warfarin reversal with frozen plasma versus prothrombin complex concentrate in the emergency department"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46; Hickey"
                            1 => "M&#46; Gatien"
                            2 => "M&#46; Taljaard"
                            3 => "A&#46; Aujnarain"
                            4 => "A&#46; Giulivi"
                            5 => "J&#46;J&#46; Perry"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.113.001875"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2013"
                        "volumen" => "128"
                        "paginaInicial" => "360"
                        "paginaFinal" => "364"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23770745"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding&#58; a randomized&#44; plasma-controlled&#44; phase IIIb study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Sarode"
                            1 => "T&#46;J&#46; Milling Jr&#46;"
                            2 => "M&#46;A&#46; Refaai"
                            3 => "A&#46; Mangione"
                            4 => "A&#46; Schneider"
                            5 => "B&#46;L&#46; Durn"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.113.002283"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2013"
                        "volumen" => "128"
                        "paginaInicial" => "1234"
                        "paginaFinal" => "1243"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23935011"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Race against the clock&#58; overcoming challenges in the management of anticoagulant-associated intracerebral hemorrhage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Le Roux"
                            1 => "C&#46;V&#46; Pollack Jr&#46;"
                            2 => "M&#46; Milan"
                            3 => "A&#46; Schaefer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/2014.6.GKS141282"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "2014"
                        "volumen" => "121"
                        "numero" => "Suppl&#46;"
                        "paginaInicial" => "1"
                        "paginaFinal" => "20"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25434932"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of warfarin-associated intracerebral hemorrhage&#58; literature review and expert opinion"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;I&#46; Aguilar"
                            1 => "R&#46;G&#46; Hart"
                            2 => "C&#46;S&#46; Kase"
                            3 => "W&#46;D&#46; Freeman"
                            4 => "B&#46;J&#46; Hoeben"
                            5 => "R&#46;C&#46; Garcia"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.4065/82.1.82"
                      "Revista" => array:6 [
                        "tituloSerie" => "Mayo Clin Proc"
                        "fecha" => "2007"
                        "volumen" => "82"
                        "paginaInicial" => "82"
                        "paginaFinal" => "92"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17285789"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ultra-rapid management of oral anticoagulant therapy-related surgical intracranial hemorrhage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Vigue"
                            1 => "C&#46; Ract"
                            2 => "B&#46; Tremey"
                            3 => "N&#46; Engrand"
                            4 => "P&#46;E&#46; Leblanc"
                            5 => "A&#46; Decaux"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-007-0528-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2007"
                        "volumen" => "33"
                        "paginaInicial" => "721"
                        "paginaFinal" => "725"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17260127"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reversal of warfarin-induced excessive anticoagulation with recombinant human factor VIIa concentrate"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;A&#46; Deveras"
                            1 => "C&#46;M&#46; Kessler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2002"
                        "volumen" => "137"
                        "paginaInicial" => "884"
                        "paginaFinal" => "888"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12458988"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Use of recombinant factor VIIa in patients with warfarin-associated intracranial hemorrhage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;L&#46; Brody"
                            1 => "V&#46; Aiyagari"
                            2 => "A&#46;M&#46; Shackleford"
                            3 => "M&#46;N&#46; Diringer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1385/NCC:2:3:263"
                      "Revista" => array:6 [
                        "tituloSerie" => "Neurocrit Care"
                        "fecha" => "2005"
                        "volumen" => "2"
                        "paginaInicial" => "263"
                        "paginaFinal" => "267"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16159073"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety of recombinant activated factor VII in randomized clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Levi"
                            1 => "J&#46;H&#46; Levy"
                            2 => "H&#46;F&#46; Andersen"
                            3 => "D&#46; Truloff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa1006221"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2010"
                        "volumen" => "363"
                        "paginaInicial" => "1791"
                        "paginaFinal" => "1800"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21047223"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;A&#46; Mayer"
                            1 => "N&#46;C&#46; Brun"
                            2 => "K&#46; Begtrup"
                            3 => "J&#46; Broderick"
                            4 => "S&#46; Davis"
                            5 => "M&#46;N&#46; Diringer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0707534"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2008"
                        "volumen" => "358"
                        "paginaInicial" => "2127"
                        "paginaFinal" => "2137"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18480205"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Novel oral anticoagulants and their role in clinical practice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;K&#46; Wittkowsky"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1592/phco.31.12.1175"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pharmacotherapy"
                        "fecha" => "2011"
                        "volumen" => "31"
                        "paginaInicial" => "1175"
                        "paginaFinal" => "1191"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22122180"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Ficha t&#233;cnica Praxbind&#46; Available from&#58; <a href="http://www.ema.europa.eu/docs/es_ES/document_library/EPAR_-">http&#58;&#47;&#47;www&#46;ema&#46;europa&#46;eu&#47;docs&#47;es&#95;ES&#47;document&#95;library&#47;EPAR&#95;-</a> &#91;accessed 17&#46;06&#46;17&#93;&#46;"
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perioperative management of antithrombotic therapy&#58; antithrombotic therapy and prevention of thrombosis&#44; 9th ed&#58; American College of Chest Physicians Evidence-Based Clinical Practice Guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;D&#46; Douketis"
                            1 => "A&#46;C&#46; Spyropoulos"
                            2 => "F&#46;A&#46; Spencer"
                            3 => "M&#46; Mayr"
                            4 => "A&#46;K&#46; Jaffer"
                            5 => "M&#46;H&#46; Eckman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.11-2298"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2012"
                        "volumen" => "141"
                        "paginaInicial" => "e326S"
                        "paginaFinal" => "e350S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22315266"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0275"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Validation of clinical classification schemes for predicting stroke&#58; results from the National Registry of Atrial Fibrillation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "B&#46;F&#46; Gage"
                            1 => "A&#46;D&#46; Waterman"
                            2 => "W&#46; Shannon"
                            3 => "M&#46; Boechler"
                            4 => "M&#46;W&#46; Rich"
                            5 => "M&#46;J&#46; Radford"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2001"
                        "volumen" => "285"
                        "paginaInicial" => "2864"
                        "paginaFinal" => "2870"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11401607"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0280"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach&#58; the euro heart survey on atrial fibrillation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46;Y&#46; Lip"
                            1 => "R&#46; Nieuwlaat"
                            2 => "R&#46; Pisters"
                            3 => "D&#46;A&#46; Lane"
                            4 => "H&#46;J&#46; Crijns"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.09-1584"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2010"
                        "volumen" => "137"
                        "paginaInicial" => "263"
                        "paginaFinal" => "272"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19762550"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0285"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of intracranial bleeding associated with anticoagulation&#58; balancing the risk of further bleeding against thromboembolism from prosthetic heart valves"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Crawley"
                            1 => "D&#46; Bevan"
                            2 => "D&#46; Wren"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurol Neurosurg Psychiatry"
                        "fecha" => "2000"
                        "volumen" => "69"
                        "paginaInicial" => "396"
                        "paginaFinal" => "398"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10945818"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Optimal timing of resumption of warfarin after intracranial hemorrhage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Majeed"
                            1 => "Y&#46;K&#46; Kim"
                            2 => "R&#46;S&#46; Roberts"
                            3 => "M&#46; Holmstrom"
                            4 => "S&#46; Schulman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/STROKEAHA.110.593087"
                      "Revista" => array:6 [
                        "tituloSerie" => "Stroke"
                        "fecha" => "2010"
                        "volumen" => "41"
                        "paginaInicial" => "2860"
                        "paginaFinal" => "2866"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21030703"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0295"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy &#40;PATCH&#41;&#58; a randomised&#44; open-label&#44; phase 3 trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;I&#46; Baharoglu"
                            1 => "C&#46; Cordonnier"
                            2 => "R&#46; Al-Shahi Salman"
                            3 => "K&#46; de Gans"
                            4 => "M&#46;M&#46; Koopman"
                            5 => "A&#46; Brand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(16)30392-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2016"
                        "volumen" => "387"
                        "paginaInicial" => "2605"
                        "paginaFinal" => "2613"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27178479"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0300"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Normalization of platelet reactivity in clopidogrel-treated subjects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Vilahur"
                            1 => "B&#46;G&#46; Choi"
                            2 => "M&#46;U&#46; Zafar"
                            3 => "J&#46;F&#46; Viles-Gonzalez"
                            4 => "D&#46;A&#46; Vorchheimer"
                            5 => "V&#46; Fuster"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1538-7836.2006.02245.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thromb Haemost"
                        "fecha" => "2007"
                        "volumen" => "5"
                        "paginaInicial" => "82"
                        "paginaFinal" => "90"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17239165"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#91;Clinical practice guidelines for the perioperative management of antiplatelet therapy in noncardiac surgery &#40;Sociedad Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n&#41;&#93;"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Sociedad Espa&#241;ola de Anestesiolog&#237;a y Reanimaci&#243;n"
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Sierra"
                            1 => "A&#46; Gomez-Luque"
                            2 => "J&#46; Castillo"
                            3 => "J&#46;V&#46; Llau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Anestesiol Reanim"
                        "fecha" => "2011"
                        "volumen" => "58"
                        "paginaInicial" => "243"
                        "paginaFinal" => "250"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21608281"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Periprocedural bridging anticoagulation&#58; current perspectives"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "C&#46; Palaniswamy"
                            1 => "D&#46;R&#46; Selvaraj"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/MJT.0b013e3181d41ed6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Ther"
                        "fecha" => "2011"
                        "volumen" => "18"
                        "paginaInicial" => "e89"
                        "paginaFinal" => "e94"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20228672"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Safety of discontinuation of anticoagulation in patients with intracranial hemorrhage at high thromboembolic risk"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46;G&#46; Phan"
                            1 => "M&#46; Koh"
                            2 => "Wijdicks EF&#58;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Neurol"
                        "fecha" => "2000"
                        "volumen" => "57"
                        "paginaInicial" => "1710"
                        "paginaFinal" => "1713"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11115236"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anticoagulation&#44; novel agents&#44; and procedures&#58; can we pardon the interruption&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "D&#46;A&#46; Garcia"
                            1 => "C&#46;B&#46; Granger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.112.115188"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2012"
                        "volumen" => "126"
                        "paginaInicial" => "255"
                        "paginaFinal" => "257"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22700855"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/25298496/0000002800000006/v1_201711300819/S2529849617300461/v1_201711300819/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "63440"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Special article"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/25298496/0000002800000006/v1_201711300819/S2529849617300461/v1_201711300819/en/main.pdf?idApp=UINPBA00004B&text.app=https://revistaneurocirugia.com/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849617300461?idApp=UINPBA00004B"
]

Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter