It is well-established that patients on anticoagulant therapy who experience spontaneous intracerebral hemorrhage (sICH) tend to present with larger hematoma volumes, greater hematoma expansion, and higher mortality rates. Determining the optimal timing for restarting anticoagulation after sICH remains a clinical challenge; delayed initiation increases the risk of ischemic complications, whereas premature resumption may lead to hemorrhagic recurrence. Furthermore, the prevalence of patients requiring anticoagulation is steadily increasing due to an aging population in many countries, including South Korea [3].

This retrospective cohort study included 90 patients from a tertiary hospital in South Korea between June 2000 and May 2022. All participants had experienced sICH while on anticoagulant therapy and resumed treatment within 6 months of the ictus. Patients with trauma-related hemorrhages or early postictus fatalities were excluded. The primary exposure variable was the interval between sICH onset and the resumption of anticoagulation. Multivariate analysis was performed to identify risk factors for post-resumption complications, while receiver operating characteristic (ROC) analysis and locally estimated scatterplot smoothing (LOESS) were employed to determine the optimal timing for resumption.

The median age of the cohort was 71 years, and 56.7% were male. Prior to sICH, warfarin was the most frequently used anticoagulant (63.3%), followed by non-vitamin K antagonist oral anticoagulants (NOACs; 22.2%). Management was predominantly conservative (57.8%), with fewer patients undergoing surgical interventions, such as craniotomy/craniectomy (13.3%) or external ventricular drainage (EVD) placement (5.6%). Within 6 months of resuming anticoagulants, nine patients experienced hemorrhagic complications and 13 experienced ischemic events. Age ≥80 years was significantly associated with ischemic events (odds ratio [OR], 4.29; p=0.048), whereas NOAC use was strongly associated with hemorrhagic complications (OR, 16.59; p=0.003). Although ROC analysis suggested potential cut-off points for resumption at day 30 for ischemic risk and day 7.5 for hemorrhagic risk, the AUC values did not reach statistical significance. However, risk modeling using LOESS curves indicated that the combined risk of complications was minimized when anticoagulants were resumed between days 20 and 22 following the ictus.

The paucity of cases involving surgical intervention, coupled with the inherent constraints of the total sample size, precluded a comprehensive subgroup analysis for these patients; thus, the applicability of our results to those undergoing non-conservative management should be interpreted with caution. Notwithstanding these limitations, this research provides valuable insights by identifying the timeframe for anticoagulant resumption after sICH that best minimizes the competing risks of bleeding and thromboembolism.

Normal pressure hydrocephalus (NPH) is characterized by the triad of cognitive decline, gait disturbance, and urinary incontinence, and may require shunt surgery. In Korea, ventriculoperitoneal (VP) shunts have traditionally been the primary method of treatment. Although lumboperitoneal shunts (LPSs) were introduced in the late 1990s, they were not widely utilized due to the lack of available programmable valves [2]. However, in 2020, Medtronic released a programmable valve specifically for LPS, which subsequently received approval from the Ministry of Food and Drug Safety (MFDS) in Korea. Since then, the frequency of LPS procedures has been steadily increasing.

While numerous studies investigating the efficacy of LPSs in patients with NPH have been published internationally, large-scale research remains limited in South Korea. The authors aimed to evaluate the clinical outcomes and complications associated with LPS in NPH patients, with a specific focus on analyzing how the type of anesthesia and valve pressure management protocols influence surgical results. A retrospective review was conducted of 244 patients with NPH who underwent LPS surgery between February 2020 and February 2025. Valve pressures were initially set at the highest level and gradually adjusted downward based on clinical response. Functional outcomes—including the modified Rankin scale (mRS), timed up and go (TUG), 10-m gait test, and Mini-Mental State Examination (MMSE)—were assessed at 1 year and followed for up to 4 years.

Among 244 patients, 119 completed at least 1 year of follow-up. At 1 year, 53.8% of patients showed mRS improvement, and 66.4% demonstrated gait improvements (TUG and 10-m walk). Stable or improved function was observed in 93.3% of patients. MMSE scores did not show significant change. The overall complication rate was 16.8%, with 11.1% requiring surgical revision, primarily for chronic subdural hematoma and catheter-related issues. No surgery-related mortality occurred, but three patients (1.2%) died from falls despite improved gait, underscoring the need for fall prevention. The adoption of an initial high-pressure setting reduced overdrainage-related complications, contributing to a decreased annual revision rate of 5.6%.

The procedure’s effectiveness in restoring cerebrospinal fluid dynamics, along with its lower morbidity and reduced hospital stay, makes it a favorable option for elderly patients who may have increased surgical risks. A retrospective study showed that LPS surgery with local anesthesia is effective for NPH patients, demonstrating favorable functional outcomes and acceptable complications. Using higher initial valve pressures significantly decreased the need for revision surgeries and complications related to overdrainage. This study is significant in that it demonstrates the efficacy of LPSs in improving NPH symptoms while reducing the surgical burden on patients through its inherently less invasive nature. Furthermore, it highlights that complications related to overdrainage can be mitigated by a pressure management strategy of initially setting a high valve pressure and subsequently tapering it down.