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Menditto VG, Rossetti G, Sampaolesi M, Buzzo M, Pomponio G. Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department. J Clin Med 2024; 13:3669. [PMID: 38999235 PMCID: PMC11242576 DOI: 10.3390/jcm13133669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/15/2024] [Accepted: 06/17/2024] [Indexed: 07/14/2024] Open
Abstract
The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a "take home message" is stated.
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Affiliation(s)
- Vincenzo G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giulia Rossetti
- Internal Medicine, Santa Croce Hospital AST1 Pesaro Urbino, 61032 Fano, Italy
| | - Mattia Sampaolesi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Marta Buzzo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
| | - Giovanni Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy
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Ghafil C, Park C, Yu J, Drake A, Sundaram S, Thiele L, Graham C, Inaba K, Matsushima K. The risk of hemorrhagic complications after anticoagulation therapy in trauma patients: A multicenter evaluation. J Trauma Acute Care Surg 2024; 96:757-762. [PMID: 37962213 PMCID: PMC11043002 DOI: 10.1097/ta.0000000000004209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND The use of anticoagulation therapy (ACT) in trauma patients during the postinjury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions. METHODS In this retrospective cohort study, all trauma admissions at two Level I trauma centers between January 2015 and December 2020 were reviewed. Patients with preexisting ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury. RESULTS A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the postinjury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7 days to 14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively. CONCLUSION The use of ACT in trauma during the postinjury period is not without risk. Waiting 7 days to 14 days postinjury might greatly reduce the risk of hemorrhagic complications. LEVEL OF EVIDENCE Therapeutic/Care Management Study; Level IV.
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Affiliation(s)
- Cameron Ghafil
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Caroline Park
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Jeremy Yu
- Department of Preventive Medicine, University of Southern California, 1845 N Soto St. Los Angeles, CA, USA 90032
| | - Andrew Drake
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Shivani Sundaram
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Lisa Thiele
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Caleb Graham
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Kenji Inaba
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
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Pan L, Hu J. Effect of prior anticoagulation therapy on outcomes of traumatic brain injury: A systematic review and meta‑analysis. Exp Ther Med 2024; 27:160. [PMID: 38476913 PMCID: PMC10928994 DOI: 10.3892/etm.2024.12448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/02/2024] [Indexed: 03/14/2024] Open
Abstract
Anticoagulants are commonly prescribed for multiple conditions. However, their influence on traumatic brain injury (TBI) outcomes, especially mortality, is not clear. The present study aimed to explore the effect of prior anticoagulation treatment on the outcomes of TBI. PubMed, Embase, Cochrane Central Register of Controlled Trials, Scopus and CINAHL databases were systematically searched for studies on individuals diagnosed with TBI, with a subgroup on prior anticoagulation therapy. Outcomes of interest included overall mortality, in-hospital mortality, length of hospital and intensive care unit stay, need for neurosurgical intervention and discharge rate. Cohort and case-control studies, published up to September 2023, were examined. Analysis was performed using STATA version 14.2 software and the Newcastle Ottawa Scale was used for bias assessment. A total of 22 studies (102,036 participants) were included in the analysis. Patients with TBI with prior anticoagulation treatment showed a statistically higher overall mortality risk [odds ratio (OR): 1.967, 95% confidence interval (CI): 1.481-2.613]. Subgroup analyses revealed age-specific and TBI severity-specific variations. Prior anticoagulation treatment was associated with a 1.860-times higher rate of in-hospital mortality and a significantly increased likelihood of requiring neurosurgical intervention (OR: 1.351, 95%CI: 1.068-1.708). However, no significant difference was noted in lengths of hospital or ICU stays. Patients with TBI and prior anticoagulation therapy are at higher risk of overall and in-hospital mortality and have significantly higher likelihood of needing neurosurgical interventions. The results emphasized the need for tailored therapeutic approach and more comprehensive clinical guidelines. Future investigations on specific anticoagulant types and immediate post-TBI interventions could offer further insights.
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Affiliation(s)
- Linghong Pan
- Department of Emergency, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Jiayao Hu
- Department of Emergency, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
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Whitehead B, Corbin D, Albowaidey A, Zhang N, Karelina K, Weil ZM. Mild traumatic brain injury induces pericyte detachment independent of stroke vulnerability. Neurosci Lett 2024; 818:137552. [PMID: 37949292 PMCID: PMC10913758 DOI: 10.1016/j.neulet.2023.137552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 11/12/2023]
Abstract
Mild traumatic brain injury (mTBI) is an independent risk factor for ischemic stroke and can result in poorer outcomes- an effect presumed to involve the cerebral vasculature. Here we tested the hypothesis that mTBI-induced pericyte detachment from the cerebrovascular endothelium is responsible for worsened stroke outcomes. We performed a mild closed-head injury and/or treated C57/bl6 mice with imatinib mesylate, a tyrosine kinase inhibitor that induces pericyte detachment. The time course of pericyte detachment was assessed 7, 14, and 28 days post injury (DPI). To test the role of pericytes in TBI-induced exacerbation of ischemic stroke outcomes, we induced mTBI and/or treated mice with imatinib for one week prior to transient middle cerebral artery occlusion. We found that injury promoted pericyte detachment from the vasculature commensurate with the levels of detachment seen in imatinib-only treated animals, and that the detachment persisted for at least 14DPI, but recovered to sham levels by 28DPI. Further, mTBI, but not imatinib-induced pericyte detachment, increased infarct volume. Thus, we conclude that the transient detachment of pericytes caused by mTBI may not be sufficient to exacerbate subsequent ischemic stroke damage. These data have important implications for understanding cerebrovascular dysfunction following mTBI and potential mechanisms of increased risk for future ischemic strokes.
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Affiliation(s)
- Bailey Whitehead
- Department of Neuroscience and Rockefeller Neuroscience Institute, West Virginia University, 108 Biomedical Rd, Morgantown, WV, 26506, USA.
| | - Deborah Corbin
- Department of Neuroscience and Rockefeller Neuroscience Institute, West Virginia University, 108 Biomedical Rd, Morgantown, WV, 26506, USA
| | - Ali Albowaidey
- Department of Neuroscience and Rockefeller Neuroscience Institute, West Virginia University, 108 Biomedical Rd, Morgantown, WV, 26506, USA
| | - Ning Zhang
- Department of Neuroscience and Rockefeller Neuroscience Institute, West Virginia University, 108 Biomedical Rd, Morgantown, WV, 26506, USA
| | - Kate Karelina
- Department of Neuroscience and Rockefeller Neuroscience Institute, West Virginia University, 108 Biomedical Rd, Morgantown, WV, 26506, USA
| | - Zachary M Weil
- Department of Neuroscience and Rockefeller Neuroscience Institute, West Virginia University, 108 Biomedical Rd, Morgantown, WV, 26506, USA
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Rickard F, Gale J, Williams A, Shipway D. New horizons in subdural haematoma. Age Ageing 2023; 52:afad240. [PMID: 38167695 DOI: 10.1093/ageing/afad240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Indexed: 01/05/2024] Open
Abstract
Subdural haematoma (SDH) is a common injury sustained by older people living with frailty and multimorbidity, and typically following falls from a standing height. Anticoagulant and antiplatelet use are commonly indicated in older people with SDH, but few data inform decision-making surrounding these agents in the context of intracranial bleeding. Opposing risks of rebleeding and thrombosis must therefore be weighed judiciously. Decision-making can be complex and requires detailed awareness of the epidemiology to ensure the safest course of action is selected for each patient. Outcomes of surgical decompression in acute SDH are very poor in older people. However, burr hole drainage can be safe and effective in older adults with symptomatic chronic SDH (cSDH). Such patients need careful assessment to ensure symptoms arise from cSDH and not from coexisting medical pathology. Furthermore, the emerging treatment of middle meningeal artery embolisation offers a well-tolerated, minimally invasive intervention which may reduce the risks of rebleeding in older adults. Nonetheless, UK SDH management is heterogenous, and no accepted UK or European guidelines exist at present. Further randomised trial evidence is required to move away from clinical practice based on historic observational data.
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Affiliation(s)
- Frances Rickard
- Consultant Geriatrician, Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
| | - John Gale
- Clinical Fellow in Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
| | - Adam Williams
- Consultant Neurosurgeon, Department of Neurosurgery, North Bristol NHS Trust, Bristol, UK
| | - David Shipway
- Consultant Geriatrician, Geriatric Major Trauma, North Bristol NHS Trust, Bristol, UK
- Honorary Senior Clinical Lecturer, University of Bristol, Bristol, UK
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Jung IH, Yun JH, Kim SJ, Chung J, Lee SK. Anticoagulation and Antiplatelet Agent Resumption Timing following Traumatic Brain Injury. Korean J Neurotrauma 2023; 19:298-306. [PMID: 37840609 PMCID: PMC10567523 DOI: 10.13004/kjnt.2023.19.e42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/30/2023] [Accepted: 07/29/2023] [Indexed: 10/17/2023] Open
Abstract
Traumatic brain injury (TBI) is a major global health concern. Due to the increase in TBI incidence and the aging population, an increasing number of patients with TBI are taking antithrombotic agents for their underlying disease. When TBI occurs in patients with these diseases, there is a conflict between the disease, which requires an antithrombotic effect, and the neurosurgeon, who must minimize intracranial hemorrhage. Nevertheless, there are no clear guidelines for the reversal or resumption of antithrombotic agents when TBI occurs in patients taking antithrombotic agents. In this review article, we intend to classify antithrombotic agents and provide information on them. We also share previous studies on the reversal and resumption of antithrombotic agents in patients with TBI to help neurosurgeons in this dilemma.
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Affiliation(s)
- In-Ho Jung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jung-Ho Yun
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Sung Jin Kim
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Jaewoo Chung
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
| | - Sang Koo Lee
- Department of Neurosurgery, Dankook University College of Medicine, Cheonan, Korea
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Edlmann E, Maripi H, Whitfield P. Systematic review on traumatic intracranial haemorrhage in patients on anti-thrombotic medications; haemorrhage progression, thrombosis, and anti-thrombotic recommencement. Neurosurg Rev 2023; 46:166. [PMID: 37410188 DOI: 10.1007/s10143-023-02075-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
A large number of patients who sustain a traumatic intracranial haemorrhage (tICH) are taking anti-thrombotic (AT) medications at the time of injury. These are stopped acutely, but there is uncertainty about safe timing for recommencement. This review aimed to understand the rate of new/progressive haemorrhage, thrombosis, and death in tICH patients on ATs and the rate and timing of AT recommencement. A systematic review of OVID Medline and EMBASE from 2000 to 2021 including adult patients with tICH on ATs with reported outcomes was performed. A total of 59 observational studies (20,421 patients) were included. Most patients were elderly (mean age 74), suffering falls (78%), and had a mild head injury. The mean new/progressive haemorrhage rate during admission was 26%, mostly diagnosed on routine imaging performed within 72 h of injury, with only 8% clinically significant. Thrombotic events were reported in 17 studies; mean rate of 3% during admission, 4-9% at 30 days and 3-11% at 6 months. AT recommencement rate and timing were only reported in six studies and varied widely, with some studies demonstrating reduced thrombotic events and mortality with earlier AT recommencement. Current data is observational and sparse in relation to haemorrhage, thrombosis, and AT recommencement. There is some suggestion that early recommencement, within 7-14 days, may be beneficial but higher quality studies with more consistent data are urgently required.
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Affiliation(s)
- Ellie Edlmann
- Peninsula Medical School, Faculty of Health, University of Plymouth, PL6 8BX, Plymouth, UK.
- Department of Neurosurgery, South West Neurosurgical CentreDepartment of Neurosurgery, Southwest Neurosurgical Centre, Derriford Hospital, PL6 8DH, Plymouth, UK.
| | - Haritha Maripi
- Department of Neurosurgery, South West Neurosurgical CentreDepartment of Neurosurgery, Southwest Neurosurgical Centre, Derriford Hospital, PL6 8DH, Plymouth, UK
| | - Peter Whitfield
- Department of Neurosurgery, South West Neurosurgical CentreDepartment of Neurosurgery, Southwest Neurosurgical Centre, Derriford Hospital, PL6 8DH, Plymouth, UK
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Albrecht JS, Kumar A, Falvey JR. Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries. JAMA Surg 2023; 158:350-358. [PMID: 36696119 PMCID: PMC9878433 DOI: 10.1001/jamasurg.2022.7081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023]
Abstract
Importance Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. Objective To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. Design, Setting, and Participants This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Exposures Black or White race. Main Outcomes and Measures Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Results Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). Conclusions and Relevance This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City
| | - Jason R. Falvey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, Baltimore
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Samuel S, Menchaca C, Gusdon AM. Timing of anticoagulation for venous thromboembolism after recent traumatic and vascular brain Injury. J Thromb Thrombolysis 2023; 55:289-296. [PMID: 36479671 DOI: 10.1007/s11239-022-02745-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
Currently, there is no consensus guideline for initiating anticoagulation in patients with a traumatic or vascular brain injury. Initiating anticoagulation for management of venous thromboembolism (VTE) can vary significantly from 72 hours to 30 weeks due to the risk of hemorrhagic complications. The purpose of this study is to compare clinical outcomes using modified Rankin Score (mRS) in a patient population with early (≤ 3 days) versus late (> 3 days) initiation of therapeutic anticoagulation from the time VTE was diagnosed. This retrospective study included patients with a traumatic or vascular brain injury who developed either deep vein thrombosis (DVT) or pulmonary embolism (PE). Use of anticoagulation prior to admission, diagnosis with VTE on admission, or patients with a non-brain injury were exclusion criteria. Secondary outcomes measured were all-cause mortality, length of stay, and reasons for early interruption of anticoagulation. Therapeutic anticoagulation was started early in 76 (74%) patients compared to late initiation in 27 (26%) patients. Baseline characteristics were similar between the two groups. The mRS score 0-3 versus 4-6 was similar in patients who received early anticoagulation versus those who received it later. However, there was a trend favoring better outcomes in the early group [mRS 4-6; 78% vs. 93%; p = 0.085] and in subgroup analysis of patients with VTE diagnosed 4-7 days [mRS 4-6; 26% vs. 56%; p = 0.006] compared to the late group. In univariate and multivariable logistic regression, only age was associated with a significant worse outcome (median, IQR) 36 years (24-50) vs. 58 years (44-65) OR 1.07 (1.03-1.12); p < 0.001. In this study, early initiation of anticoagulation did not worsen clinical outcomes.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, 77030, Houston, TX, USA.
| | - Carlton Menchaca
- Department of Pharmacy, Memorial Hermann-Texas Medical Center, 6411 Fannin Street, 77030, Houston, TX, USA
| | - Aaron M Gusdon
- Department of Neurosurgery, The University of Texas McGovern Medical School at Houston, Houston, TX, USA
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Prognostic Significance of Plasma Insulin Level for Deep Venous Thrombosis in Patients with Severe Traumatic Brain Injury in Critical Care. Neurocrit Care 2022; 38:263-278. [PMID: 36114315 DOI: 10.1007/s12028-022-01588-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Whether insulin resistance underlies deep venous thrombosis (DVT) development in patients with severe traumatic brain injury (TBI) is unclear. In this study, the association between plasma insulin levels and DVT was analyzed in patients with severe TBI. METHODS A prospective observational study of 73 patients measured insulin, glucose, glucagon-like peptide 1 (GLP-1), inflammatory factors, and hematological profiles within four preset times during the first 14 days after TBI. Ultrasonic surveillance of DVT was tracked. Two-way analysis of variance was used to determine the factors that discriminated between patients with and without DVT or with and without insulin therapy. Partial correlations of insulin level with all the variables were conducted separately in patients with DVT or patients without DVT. Factors associated with DVT were analyzed by multivariable logistic regression. Neurological outcomes 6 months after TBI were assessed. RESULTS Among patients with a mean (± standard deviation) age of 53 (± 16 years), DVT developed in 20 patients (27%) on median 10.4 days (range 4-22), with higher Acute Physiology and Chronic Health Evaluation II scores but similar Sequential Organ Failure Assessment scores and TBI severity. Patients with DVT were more likely to receive insulin therapy than patients without DVT (60% vs. 28%; P = 0.012); hence, they had higher 14-day insulin levels. However, insulin levels were comparable between patients with DVT and patients without DVT in the subgroups of patients with insulin therapy (n = 27) and patients without insulin therapy (n = 46). The platelet profile significantly discriminated between patients with and without DVT. Surprisingly, none of the coagulation profiles, blood cell counts, or inflammatory mediators differed between the two groups. Patients with insulin therapy had significantly higher insulin (P = 0.006), glucose (P < 0.001), and GLP-1 (P = 0.01) levels and were more likely to develop DVT (60% vs. 15%; P < 0.001) along with concomitant platelet depletion. Insulin levels correlated with glucose, GLP-1 levels, and platelet count exclusively in patients without DVT. Conversely, in patients with DVT, insulin correlated negatively with GLP-1 levels (P = 0.016). Age (P = 0.01) and elevated insulin levels at days 4-7 (P = 0.04) were independently associated with DVT. Patients with insulin therapy also showed worse Glasgow Outcome Scale scores (P = 0.001). CONCLUSIONS Elevated insulin levels in the first 14 days after TBI may indicate insulin resistance, which is associated with platelet hyperactivity, and thus increasing the risk of DVT.
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Siletz AE, Dhillon NK, Fierro NM, Muñiz T, Loran P, Singer M, Hashim YM, Ley EJ. Complications and Transfusions on Therapeutic Anticoagulation After Trauma. Am Surg 2022; 88:2451-2455. [PMID: 35549566 DOI: 10.1177/00031348221101492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Trauma patients who develop indications for therapeutic anticoagulation (TAC) present a challenge due to concern for bleeding. Transfusion requirement has been described as a common complication of TAC after trauma but its clinical relevance is unclear. OBJECTIVE Determine risk factors for and clinical outcomes associated with transfusion requirement on TAC after trauma. METHODS All trauma patients admitted to an academic urban level I trauma center from January 2010 to August 2020 who received TAC were included in this retrospective cohort study. Data included injury characteristics; TAC indication and timing; transfusions; and interventions. Patients who required transfusion after TAC were compared to those who did not. RESULTS Eighty-two patients were included. The most common reasons for TAC were deep vein thrombosis (67.1%) and pulmonary embolism (31.7%). Two (2.4%) patients developed gastrointestinal bleeding. One (1.2%) underwent endoscopic intervention. Two patients (4.9%) had intracranial hemorrhage progression. Blood transfusion after TAC initiation was required in 43.9% of patients. Patients who were transfused started TAC more quickly after traumatic injury (5.5 vs 10.0 days, P = .03), had fewer hospital-free days (54 vs 64 days, P < .01), ICU-free days (8.5 vs 16.5 days, P = .01), and higher mortality (13.9% vs 2.1%, P = .04). CONCLUSION Transfusions are common after starting TAC in trauma patients. Requiring transfusion after starting TAC was associated with shorter time from injury to starting TAC, higher mortality, and fewer ICU and hospital-free days.
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Affiliation(s)
| | | | | | - Tobias Muñiz
- 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Priya Loran
- 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Eric J Ley
- 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Kobeissy F, Mallah K, Zibara K, Dakroub F, Dalloul Z, Nasser M, Nasrallah L, Mallah Z, El-Achkar GA, Ramadan N, Mohamed W, Mondello S, Hamade E, Habib A. The effect of clopidogrel and aspirin on the severity of traumatic brain injury in a rat model. Neurochem Int 2022; 154:105301. [PMID: 35121011 DOI: 10.1016/j.neuint.2022.105301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 01/07/2022] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
Traumatic Brain Injury (TBI) is one of the leading causes of death and disability worldwide. Aspirin (ASA) and clopidogrel (CLOP) are antiplatelet agents that inhibit platelet aggregation. They are implicated in worsening the intracerebral haemorrhage (ICH) risk post-TBI. However, antiplatelet drugs may also exert a neuroprotective effect post-injury. We determined the impact of aspirin and clopidogrel treatment, alone or in combination, on ICH and brain damage in an experimental rat TBI model. We assessed changes in platelet aggregation and measured serum thromboxane by enzyme immune assay. We also explored a panel of brain damage and apoptosis biomarkers by immunoblotting. Rats were treated with aspirin and/or clopidogrel for 48 h prior to TBI and sacrificed 48 h post-injury. In rats treated with antiplatelet agents prior to TBI, platelet aggregation was completely inhibited, and serum thromboxane was significantly decreased, compared to the TBI group without treatment. TBI increases UCHL-1 and GFAP, but decreases hexokinase expression compared to the non-injured controls. All groups treated with antiplatelet drugs prior to TBI had decreased UCH-L1 and GFAP serum levels compared to the TBI untreated group. Furthermore, the ASA and CLOP single treatments increased the hexokinase serum levels. We confirmed that αII-spectrin cleavage increased post-TBI, with the highest cleavage detected in CLOP-treated rats. Aspirin and/or clopidogrel treatment prior to TBI is a double-edged sword that exerts a dual effect post-injury. On one hand, ASA and CLOP single treatments increase the post-TBI ICH risk, with a further detrimental effect from the ASA + CLOP treatment. On the other hand, ASA and/or CLOP treatments are neuroprotective and result in a favourable profile of TBI injury markers. The ICH risk and the neuroprotection benefits from antiplatelet therapy should be weighed against each other to ameliorate the management of TBI patients.
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Affiliation(s)
- Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Khalil Mallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Department of Microbiology and Immunology, Medical University of South Carolina, 173 Ashley Avenue, BSB 204, MSC 504, Charleston, SC, 29425, USA
| | - Kazem Zibara
- ER045, Laboratory of Stem Cells, DSST, PRASE, Lebanese University, Beirut, Lebanon; Department of Biology, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Fatima Dakroub
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Zeinab Dalloul
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Mohammad Nasser
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Leila Nasrallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Zahraa Mallah
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon
| | - Ghewa A El-Achkar
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Naify Ramadan
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Wael Mohamed
- Clinical Pharmacology Department, Menoufia Medical School, Menoufia University, AlMinufya, Egypt; Basic Medical Science Department, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | | | - Eva Hamade
- Molecular Biology and Cancer Immunology Laboratory, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon; Department of Biochemistry, Faculty of Sciences-I, Lebanese University, Beirut, Lebanon.
| | - Aida Habib
- Department of Basic Medical Sciences, QU Health, Qatar University, Doha, Qatar.
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13
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Feldeisen T, Alexandris-Souphis C, Haymart B, Kong X, Kline-Rogers E, Handoo F, Scott K, Ali M, Kozlowski J, Shah V, Krol G, Froehlich JB, Barnes GD. Anticoagulation Changes Following Major and Clinically Relevant Nonmajor Bleeding Events in Non-valvular Atrial Fibrillation Patients. J Pharm Pract 2021; 36:542-547. [PMID: 34962835 DOI: 10.1177/08971900211064189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bleeding events are common complications of oral anticoagulant drugs, including both warfarin and the direct oral anticoagulants (DOACs). Some patients have their anticoagulant changed or discontinued after experiencing a bleeding event, while others continue the same treatment. Differences in anticoagulation management between warfarin- and DOAC-treated patients following a bleeding event are unknown. METHODS Patients with non-valvular atrial fibrillation from six anticoagulation clinics taking warfarin or DOAC therapy who experienced an International Society of Thrombosis and Haemostasis (ISTH)-defined major or clinically relevant non-major (CRNM) bleeding event were identified between 2016 and 2020. The primary outcome was management of the anticoagulant following bleeding (discontinuation, change in drug class, and restarting of same drug class). DOAC- and warfarin-treated patients were propensity matched based on the individual elements of the CHA2DS2-VASc and HAS-BLED scores as well as the severity of the bleeding event. RESULTS Of the 509 patients on warfarin therapy and 246 on DOAC therapy who experienced a major or CRNM bleeding event, the majority of patients continued anticoagulation therapy. The majority of warfarin (231, 62.6%) and DOAC patients (201, 81.7%) restarted their previous anticoagulation. CONCLUSION Following a bleeding event, most patients restarted anticoagulation therapy, most often with the same type of anticoagulant that they previously had been taking.
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Affiliation(s)
- Thane Feldeisen
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | | | - Brian Haymart
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Xiaowen Kong
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Eva Kline-Rogers
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Faheem Handoo
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | | | - Mona Ali
- 21818William Beaumont Hospital, Royal Oak, MI, USA
| | - Jay Kozlowski
- 22945DMC Huron Valley-Sinai Hospital, Commerce Township, MI, USA
| | - Vinay Shah
- 2971Henry Ford Hospital, Detroit, MI, USA
| | | | - James B Froehlich
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, 21614Michigan Medicine, Ann Arbor, MI, USA
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14
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Feugray G, Kasonga F, Chamouni P, Barbay V, Fresel M, Hélène Chretien M, Brunel S, Le Cam Duchez V, Billoir P. Factor XII deficiency evaluated by thrombin generation assay. Clin Biochem 2021; 100:42-47. [PMID: 34843733 DOI: 10.1016/j.clinbiochem.2021.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/06/2021] [Accepted: 11/22/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Coagulation factor XII (FXII) plays a role in thrombin generation, fibrinolysis, inflammation, angiogenesis, chemotaxis and diapedesis. FXII deficiency is not associated with bleeding risk unlike other coagulation factors. MATERIALS/METHODS We investigated thrombin generation assay (TGA) profile modification in FXII deficiency and the correlation with TGA and deficiency severity. TGA was performed in platelet poor plasma (PPP) with tissue factor (1 pmol/L) and phospholipid (4 µmol/L) standardized concentration. Thrombin generation profiles were compared in 54 patients with FXII deficiency, 25 healthy controls and 23 patients with hemophilia A (factor VIII (FVIII) deficiency. Patients with FXII deficiency were classified in three groups based on FXII activity (30-50%, 10-29%, <10%). FVIII deficiency was included as a bleeding control group. RESULTS As expected, we found a correlation between FXII deficiency and activated partial thromboplastin time (aPTT). A decrease of thrombin generation was observed in healthy controls and all FXII deficiency groups. A decrease of endogenous thrombin potential (ETP), peak and velocity was observed in patients with FVIII deficiency compared to FXII deficiency. A decrease of thrombin generation was noted in patients with FXII deficiency and bleeding history compared to patients with FXII deficiency and thrombosis history. CONCLUSION In this study, thrombin generation profiles were not sensitive to FXII deficiency. TGA could distinguish bleeding and thrombotic tendency in FXII deficiency. Our results should therefore be considered as exploratory and deserve confirmation.
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Affiliation(s)
- Guillaume Feugray
- Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Fiston Kasonga
- Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Pierre Chamouni
- Rouen University Hospital, Hemophilia Care Center, F 76000 Rouen, France
| | - Virginie Barbay
- Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France; Rouen University Hospital, Hemophilia Care Center, F 76000 Rouen, France
| | - Marielle Fresel
- Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | | | - Sabine Brunel
- Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Véronique Le Cam Duchez
- Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Paul Billoir
- Normandie Univ, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France.
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15
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Weil ZM, Karelina K, Whitehead B, Velazquez-Cruz R, Oliverio R, Pinti M, Nwafor DC, Nicholson S, Fitzgerald JA, Hollander J, Brown CM, Zhang N, DeVries AC. Mild traumatic brain injury increases vulnerability to cerebral ischemia in mice. Exp Neurol 2021; 342:113765. [PMID: 33992581 DOI: 10.1016/j.expneurol.2021.113765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/15/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
Recent studies have reported that TBI is an independent risk factor for subsequent stroke. Here, we tested the hypothesis that TBI would exacerbate experimental stroke outcomes via alternations in neuroimmune and neurometabolic function. We performed a mild closed-head TBI and then one week later induced an experimental stroke in adult male mice. Mice that had previously experienced TBI exhibited larger infarcts, greater functional deficits, and more pronounced neuroinflammatory responses to stroke. We hypothesized that impairments in central metabolic physiology mediated poorer outcomes after TBI. To test this, we treated mice with the insulin sensitizing drug pioglitazone (Pio) after TBI. Pio prevented the exacerbation of ischemic outcomes induced by TBI and also blocked the induction of insulin insensitivity by TBI. However, tissue respiratory function was not improved by Pio. Finally, TBI altered microvascular responses including promoting vascular accumulation of serum proteins and significantly impairing blood flow during the reperfusion period after stroke, both of which were reversed by treatment with Pio. Thus, TBI appears to exacerbate ischemic outcomes by impairing metabolic and microvascular physiology. These data have important implications because TBI patients experience strokes at greater rates than individuals without a history of head injury, but these data suggest that those strokes may also cause greater tissue damage and functional impairments in that population.
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Affiliation(s)
- Zachary M Weil
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA.
| | - Kate Karelina
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - Bailey Whitehead
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - Ruth Velazquez-Cruz
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - Robin Oliverio
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - Mark Pinti
- Department of Exercise Physiology, West Virginia University School of Medicine, 1 Medical Center Dr., Morgantown, WV 26506, USA; Mitochondria, Metabolism, & Bioenergetics Working Group, West Virginia University School of Medicine, 1 Medical Center Dr., Morgantown, WV 26506, USA
| | - Divine C Nwafor
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - Samuel Nicholson
- Department of Neuroscience, Ohio State University, 460 West 12th Ave., Columbus, OH 43210, USA
| | - Julie A Fitzgerald
- Department of Neuroscience, Ohio State University, 460 West 12th Ave., Columbus, OH 43210, USA
| | - John Hollander
- Department of Exercise Physiology, West Virginia University School of Medicine, 1 Medical Center Dr., Morgantown, WV 26506, USA; Mitochondria, Metabolism, & Bioenergetics Working Group, West Virginia University School of Medicine, 1 Medical Center Dr., Morgantown, WV 26506, USA
| | - Candice M Brown
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - Ning Zhang
- Department of Neuroscience, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
| | - A Courtney DeVries
- Department of Medicine, WVU Cancer Institute, WVU Rockefeller Neuroscience Institute, West Virginia University, BMRC, 1 Medical Center Dr., PO Box 9303, Morgantown, WV 26506, USA
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16
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Turner GM, McMullan C, Aiyegbusi OL, Bem D, Marshall T, Calvert M, Mant J, Belli A. Stroke risk following traumatic brain injury: Systematic review and meta-analysis. Int J Stroke 2021; 16:370-384. [PMID: 33705244 PMCID: PMC8193616 DOI: 10.1177/17474930211004277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Traumatic brain injury is a global health problem; worldwide, >60 million people experience a traumatic brain injury each year and incidence is rising. Traumatic brain injury has been proposed as an independent risk factor for stroke. Aims To investigate the association between traumatic brain injury and stroke risk. Summary of review We undertook a systematic review of MEDLINE, EMBASE, CINAHL, and The Cochrane Library from inception to 4 December 2020. We used random-effects meta-analysis to pool hazard ratios for studies which reported stroke risk post-traumatic brain injury compared to controls. Searches identified 10,501 records; 58 full texts were assessed for eligibility and 18 met the inclusion criteria. The review included a large sample size of 2,606,379 participants from four countries. Six studies included a non-traumatic brain injury control group, all found traumatic brain injury patients had significantly increased risk of stroke compared to controls (pooled hazard ratio 1.86; 95% confidence interval 1.46–2.37). Findings suggest stroke risk may be highest in the first four months post-traumatic brain injury, but remains significant up to five years post-traumatic brain injury. Traumatic brain injury appears to be associated with increased stroke risk regardless of severity or subtype of traumatic brain injury. There was some evidence to suggest an association between reduced stroke risk post-traumatic brain injury and Vitamin K antagonists and statins, but increased stroke risk with certain classes of antidepressants. Conclusion Traumatic brain injury is an independent risk factor for stroke, regardless of traumatic brain injury severity or type. Post-traumatic brain injury review and management of risk factors for stroke may be warranted.
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Affiliation(s)
- Grace M Turner
- Centre for Patient Reported Outcomes Research, College of Medical and Dental Sciences, 1724University of Birmingham, Birmingham, UK
| | - Christel McMullan
- Centre for Patient Reported Outcomes Research, College of Medical and Dental Sciences, 1724University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust and 1724University of Birmingham, Birmingham, UK.,Institute of Applied Health Research, 1724University of Birmingham, Birmingham, UK
| | - Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, College of Medical and Dental Sciences, 1724University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust and 1724University of Birmingham, Birmingham, UK.,Institute of Applied Health Research, 1724University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and 1724University of Birmingham, Birmingham, UK.,Birmingham Health Partners Centre for Regulatory Science and Innovation, 1724University of Birmingham, Birmingham, UK.,NIHR Applied Research Collaboration (ARC) West Midlands, 1724University of Birmingham, Birmingham, UK
| | - Danai Bem
- Institute of Applied Health Research, 1724University of Birmingham, Birmingham, UK
| | - Tom Marshall
- Institute of Applied Health Research, 1724University of Birmingham, Birmingham, UK
| | - Melanie Calvert
- Centre for Patient Reported Outcomes Research, College of Medical and Dental Sciences, 1724University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust and 1724University of Birmingham, Birmingham, UK.,Institute of Applied Health Research, 1724University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and 1724University of Birmingham, Birmingham, UK.,Birmingham Health Partners Centre for Regulatory Science and Innovation, 1724University of Birmingham, Birmingham, UK.,NIHR Applied Research Collaboration (ARC) West Midlands, 1724University of Birmingham, Birmingham, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, 2152University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust and 1724University of Birmingham, Birmingham, UK
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17
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Prior A, Fiaschi P, Iaccarino C, Stefini R, Battaglini D, Balestrino A, Anania P, Prior E, Zona G. How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH). BMC Neurol 2021; 21:98. [PMID: 33658003 PMCID: PMC7927258 DOI: 10.1186/s12883-021-02126-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage. METHODS We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations. RESULTS Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon. CONCLUSIONS To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.
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Affiliation(s)
- Alessandro Prior
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pietro Fiaschi
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy.
| | | | - Roberto Stefini
- Department of Neurosurgery, Ospedale Civile di Legnano, Milan, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Alberto Balestrino
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pasquale Anania
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Enrico Prior
- Division of Cardiology, Department of Medicine University of Verona, Verona, Italy
| | - Gianluigi Zona
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy
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18
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Narula N, Tsikis S, Jinadasa SP, Parsons CS, Cook CH, Butt B, Odom SR. The Effect of Anticoagulation and Antiplatelet Use in Trauma Patients on Mortality and Length of Stay. Am Surg 2021; 88:1137-1145. [PMID: 33522831 DOI: 10.1177/0003134821989043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Though many trauma patients are on anticoagulation or antiplatelet therapy (AAT), there are few generalizable data on the risks for these patients. The purpose of this study was to analyze the impact of anticoagulation (AC) and antiplatelet (AP) therapy on mortality and length of stay (LOS) in general trauma patients. METHODS A retrospective review was performed of patients in the institutional trauma registry during 2019 to determine AAT use on admission and discharge. Outcomes were compared using standard statistics. RESULTS Of 2261 patients who met the inclusion criteria, 2 were excluded due to an incomplete medication reconciliation, resulting in 2259 patients. Patients on AAT had a higher mortality (4.5% vs 2.1%). On multivariable analysis, preadmission AC (odds ratio OR, 3.325, P = .001), age (OR 1.040, P < .001), and injury severity score ((ISS) 1.094, P < .001) were associated with mortality. Anticoagulation use was also associated with longer LOS on multivariable analysis (OR: 1.626, P = .005). Antiplatelet use was not associated with higher mortality or longer LOS. More patients on AAT were unable to be discharged home. However, patients on AAT did not have a greater blood transfusion requirement or need more hemorrhage control procedures. Lastly, 23.7% of patients on preadmission AAT were not discharged on any AAT. DISCUSSION These data demonstrate that patients on AC, but not AP, have greater mortality and longer hospital LOS. This may provide guidance for those being newly started on AAT. Further work to determine which patients benefit most from restarting AAT would lead to improvement in the care of trauma patients.
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Affiliation(s)
- Nisha Narula
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Savas Tsikis
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sayuri P Jinadasa
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Charles S Parsons
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Charles H Cook
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Bonnie Butt
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stephen R Odom
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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19
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King B, Milling T, Gajewski B, Costantini TW, Wick J, Price MA, Mudaranthakam D, Stein DM, Connolly S, Valadka A, Warach S. Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials. Trauma Surg Acute Care Open 2020; 5:e000605. [PMID: 33313417 PMCID: PMC7716676 DOI: 10.1136/tsaco-2020-000605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022] Open
Abstract
Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.
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Affiliation(s)
- Ben King
- College of Medicine, Department of Health Systems and Population Health Sciences, University of Houston, Houston, Texas, USA
| | - Truman Milling
- Seton Dell Medical School Stroke Institute, Ascension Seton, Austin, Texas, USA
| | - Byron Gajewski
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, California, USA
| | - Jo Wick
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Dinesh Mudaranthakam
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Deborah M Stein
- Department of Surgery, University of California-San Francisco, School of Medicine, San Francisco, California, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Steven Warach
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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20
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Prothrombin complex concentrate for vitamin K antagonist reversal in traumatic intracranial hemorrhage. J Clin Neurosci 2020; 79:197-202. [PMID: 33070895 DOI: 10.1016/j.jocn.2020.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/28/2020] [Accepted: 07/03/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Administration of prothrombin complex concentrate (PCC) is recommended for vitamin K antagonist (VKA) reversal in patients with severe bleeding complications. However, there are only limited data available on its use for VKA reversal in patients with traumatic intracranial hemorrhage (ICH). METHODS Data from all anticoagulated patients referred to our hospital for treatment of traumatic ICH and who received PCC for anticoagulation reversal were retrospectively analysed with specific focus on bleeding and thromboembolic complications during the further in-hospital course. RESULTS A total of 142 patients were included in the present study. The median age was 78 years (Interquartile range [IQR]: 72-84) and the median Glasgow Coma Scale (GCS) score on admission was 12 (IQR: 7-14). Median International Normalized Ratio (INR) on admission was 2.5 [IQR: 2.0-3.3] and decreased to 1.2 [IQR: 1.1-1.3] following administration of a median dose of 2000 I.U. PCC [IQR: 1500-2625]. The in-hospital mortality rate was 13% and the median GCS of survivors at discharge was 14 [IQR: 12-15]. Thromboembolic events after PCC administration occurred in 4 patients (2.8%). The overall one-year mortality rate in this patient cohort was 49%. CONCLUSIONS PCC administration rapidly normalises INR and facilitates urgent neurosurgical procedures in anticoagulated patients with traumatic ICH.
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Staerk L, Fosbøl EL, Lamberts M, Bonde AN, Gadsbøll K, Sindet-Pedersen C, Holm EA, Gerds TA, Ozenne B, Lip GYH, Torp-Pedersen C, Gislason GH, Olesen JB. Resumption of oral anticoagulation following traumatic injury and risk of stroke and bleeding in patients with atrial fibrillation: a nationwide cohort study. Eur Heart J 2019; 39:1698-1705a. [PMID: 29165556 DOI: 10.1093/eurheartj/ehx598] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 10/02/2017] [Indexed: 11/14/2022] Open
Abstract
Aims We examined the risks of all-cause mortality, stroke, major bleeding, and recurrent traumatic injury associated with resumption of vitamin K antagonists (VKAs) and non-VKAs oral anticoagulants (NOACs) following traumatic injury in atrial fibrillation (AF) patients. Methods and results This was a Danish nationwide registry-based study (2005-16), including 4541 oral anticoagulant (OAC)-treated AF patients experiencing traumatic injury (defined as traumatic brain injury, hip fracture, or traumatic torso or abdominal injury). Within 90 days following discharge from traumatic injury, 60.6% resumed VKA (median age = 80, CHA2DS2-VASc = 4, HAS-BLED = 2), 16.7% resumed NOAC (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 2), and 22.7% did not resume OAC treatment (median age = 81, CHA2DS2-VASc = 4, HAS-BLED = 3). Switch from VKA to NOAC occurred among 9.5%. Since 2009, the trend in OAC resumption increased (P-value <0.0001), in particular with NOACs (P-value <0.0001). Follow-up started 90 days after discharge, and time-varying multiple Cox regression analyses were used for comparisons. Compared with non-resumption, VKA and NOAC resumption were associated with lower hazard [95% confidence interval (CI)] of all-cause mortality [hazard ratio (HR) 0.48 (0.42-0.53) and HR 0.55 (0.47-0.66), respectively] and ischaemic stroke [HR 0.56 (0.43-0.72) and HR 0.54 (0.35-0.82), respectively], increased major bleeding hazard [HR 1.30 (1.03-1.64) and HR 1.15 (0.81-1.63), respectively], and similar hazard of recurrent traumatic injury [HR 0.93 (0.73-1.18) and HR 0.87 (0.60-1.27), respectively]. Conclusion AF patients resuming VKA and NOAC treatment following traumatic injury have lower hazard of all-cause mortality and ischaemic stroke, increased hazard of major bleeding but without additional hazards of recurrent traumatic injury. Withholding OAC following a traumatic injury in AF patients may not be warranted.
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Affiliation(s)
- Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark.,The Danish Heart Association, Vognmagergade 7, 1120 Copenhagen K, Denmark
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Kasper Gadsbøll
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Caroline Sindet-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
| | - Ellen A Holm
- Department of Internal Medicine, Nykøbing F. Hospital, Fjordvej 15, 4800 Nykøbing Falster, Denmark
| | - Thomas Alexander Gerds
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark
| | - Brice Ozenne
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Fredrik Bajers vej 5, 9100 Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Epidemiology, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark.,Department of Health, Science and Technology, Aalborg University, Fredrik Bajers vej 5, 9100 Aalborg, Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark.,The Danish Heart Association, Vognmagergade 7, 1120 Copenhagen K, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark.,The National Institute of Public Health, University of Southern Denmark, Øster Farimagsgade 5, 1353 Copenhagen K, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Kildegaardsvej 28, 2900 Hellerup, Denmark
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Khokhar B, Simoni-Wastila L, Slejko JF, Perfetto E, Zhan M, Smith GS. Mortality and Associated Morbidities Following Traumatic Brain Injury in Older Medicare Statin Users. J Head Trauma Rehabil 2019; 33:E68-E76. [PMID: 29385012 PMCID: PMC6066463 DOI: 10.1097/htr.0000000000000369] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To assess the relationship between posttraumatic brain injury statin use and (1) mortality and (2) the incidence of associated morbidities, including stroke, depression, and Alzheimer's disease and related dementias following injury. SETTING AND PARTICIPANTS Nested cohort of all Medicare beneficiaries 65 years of age and older who survived a traumatic brain injury (TBI) hospitalization during 2006 through 2010. The final sample comprised 100 515 beneficiaries. DESIGN Retrospective cohort study of older Medicare beneficiaries. Relative risks (RR) and 95% confidence interval (CI) were obtained using discrete time analysis and generalized estimating equations. MEASURES The exposure of interest included monthly atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin use. Outcomes of interest included mortality, stroke, depression, and Alzheimer's disease and related dementias. RESULTS Statin use of any kind was associated with decreased mortality following TBI hospitalization discharge. Any statin use was also associated with a decrease in any stroke (RR, 0.86; 95% confidence intervals (CI), 0.81-0.91), depression (RR, 0.85; 95% CI, 0.79-0.90), and Alzheimer's disease and related dementias (RR, 0.77; 95% CI, 0.73-0.81). CONCLUSION These findings provide valuable information for clinicians treating older adults with TBI as clinicians can consider, when appropriate, atorvastatin and simvastatin to older adults with TBI in order to decrease mortality and associated morbidities.
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Affiliation(s)
- Bilal Khokhar
- General Dynamics Information Technology, Defense and Veterans Brain Injury Center, Fairfax, Virginia (Dr Khokhar); Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore (Drs Slejko, Perfetto, and Simoni-Wastila); National Health Council, Washington, District of Columbia (Dr Perfetto); Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore (Dr Zhan and Mr Smith); and West Virginia University School of Public Health, Morgantown (Mr Smith)
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Mandalaywala MD, Crawford KM, Pinto SM. Management of Traumatic Brain Injury: Special Considerations for Older Adults. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00239-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Puccio AM, Anderson MW, Fetzick A. The Transition Trajectory for the Patient with a Traumatic Brain Injury. Nurs Clin North Am 2019; 54:409-423. [PMID: 31331627 DOI: 10.1016/j.cnur.2019.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The trajectory status of patients with mild, moderate, and severe traumatic brain injury from emergency room evaluation, through acute care (intensive care if severe) and discharge is discussed. Additional considerations for elderly population and common complications associated with severe traumatic brain injury are also covered.
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Affiliation(s)
- Ava M Puccio
- Department of Neurological Surgery, Neurotrauma Clinical Trials Center, University of Pittsburgh, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA.
| | - Maighdlin W Anderson
- University of Pittsburgh School of Nursing, 324 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA
| | - Anita Fetzick
- Department of Neurological Surgery, Neurotrauma Clinical Trials Center, University of Pittsburgh, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA
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Wiegele M, Schöchl H, Haushofer A, Ortler M, Leitgeb J, Kwasny O, Beer R, Ay C, Schaden E. Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement. Crit Care 2019; 23:62. [PMID: 30795779 PMCID: PMC6387521 DOI: 10.1186/s13054-019-2352-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/10/2019] [Indexed: 12/11/2022] Open
Abstract
There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.
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Affiliation(s)
- Marion Wiegele
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020 Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
| | - Alexander Haushofer
- Central Laboratory, Klinikum Wels-Grieskirchen, Grieskirchner Str. 42, 4600 Wels, Austria
| | - Martin Ortler
- Department of Neurosurgery, Krankenhaus Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
- Department of Neurosurgery, Medical University of Innsbruck, Innrain 52, Christoph-Probst-Platz, 6020 Innsbruck, Austria
| | - Johannes Leitgeb
- University Departments of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Oskar Kwasny
- Department for Surgery and Sports Traumatology, Kepler University Hospital–Med Campus III, Krankenhausstraße 9, 4020 Linz, Austria
| | - Ronny Beer
- Neurocritical Care, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Albrecht JS, Kibria GA, Gruber-Baldini A, Magaziner J. Risk of Mortality in Individuals with Hip Fracture and Traumatic Brain Injury. J Am Geriatr Soc 2019; 67:124-127. [PMID: 30471090 PMCID: PMC6436834 DOI: 10.1111/jgs.15661] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/21/2018] [Accepted: 09/21/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To estimate the prevalence of diagnosed traumatic brain injury (TBI) in individuals hospitalized with hip fracture and examine its association with all-cause mortality. DESIGN Nested cohort study. SETTING National sample of Medicare beneficiaries from 2006 to 2010. PARTICIPANTS Beneficiaries aged 65 and older hospitalized with hip fracture. MEASUREMENTS TBI at the time of hip fracture was defined using International Classification of Diseases, Ninth Revision, Clinical Modification codes. The main outcome was all-cause mortality during follow-up. RESULTS Prevalence of TBI in individuals with hip fracture was 2.7%. Absolute risk of mortality attributable to TBI in individuals with hip fracture was 15/100 person-years. TBI was significantly associated with risk of death in multivariable analysis (hazard ratio=1.24, 95% confidence interval=1.14-1.35). CONCLUSION TBI was associated with greater risk of mortality in individuals with hip fracture. Practitioners should consider evaluating for presence of TBI in this vulnerable population. J Am Geriatr Soc 67:124-127, 2019.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Gulam Al Kibria
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Ann Gruber-Baldini
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Jay Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201
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Divito A, Kerr K, Wilkerson C, Shepard S, Choi A, Kitagawa RS. Use of Anticoagulation Agents After Traumatic Intracranial Hemorrhage. World Neurosurg 2018; 123:e25-e30. [PMID: 30528524 DOI: 10.1016/j.wneu.2018.10.173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/24/2018] [Accepted: 10/26/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Anticoagulant therapy (ACT) after traumatic intracranial hemorrhage may lead to progression of hemorrhage, but in the presence of thromboembolic events, the clinician must decide if the benefits outweigh the risks. Currently, no data exist to guide therapy in the acute setting. METHODS We retrospectively identified all patients admitted to our institution with traumatic intracranial hemorrhage that received intravenous heparin, full-dose enoxaparin, or warfarin during their initial hospitalization over a 3-year period. We reviewed their demographics, hospital course, clinical indication and timing for initiation of ACT, and complications. RESULTS A total of 112 patients were identified. The median age and Glasgow Coma Scale score of these patients was 50.5 years and 9.5, respectively. Twenty-two patients required neurosurgical procedures for their presenting injury, including intracranial pressure monitors and/or open surgeries. Fifty-four patients had deep vein thrombosis or pulmonary embolism prior to initiation, and the remaining 20 patients had preexisting conditions or other indications for initiating ACT. The median time from injury to starting ACT was 8 days. Immediate complications occurred in 6 patients; however, none of these patients required a neurosurgical intervention. Delayed complications included progression of acute to chronic subdural hematoma that required intervention in 2 patients. One patient died from delayed hemorrhage. CONCLUSIONS For this patient population, the risk of immediate and delayed intracranial hemorrhages from initiating ACT therapy in intracranial injury must be weighed against the morbidity of delaying treatment. Although further studies are needed, our review provides the first rates of complications for this patient population.
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Affiliation(s)
- Anthony Divito
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Keith Kerr
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Christopher Wilkerson
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Scott Shepard
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alex Choi
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ryan S Kitagawa
- Vivian L. Smith Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Glass NE, Vadlamani A, Hwang F, Sifri ZC, Kunac A, Bonne S, Pentakota SR, Yonclas P, Mosenthal AC, Livingston DH, Albrecht JS. Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum. J Surg Res 2018; 235:615-620. [PMID: 30691850 DOI: 10.1016/j.jss.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/22/2018] [Accepted: 10/16/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk. METHODS Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression. RESULTS Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes. CONCLUSIONS Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.
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Affiliation(s)
- Nina E Glass
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey.
| | - Aparna Vadlamani
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Franchesca Hwang
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Anastasia Kunac
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Stephanie Bonne
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Sri Ram Pentakota
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Peter Yonclas
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Anne C Mosenthal
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - David H Livingston
- Division of Trauma and Critical Care, Department of Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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Llompart-Pou JA, Pérez-Bárcena J. Geriatric traumatic brain injury: An old challenge. Med Intensiva 2018; 43:44-46. [PMID: 29661567 DOI: 10.1016/j.medin.2018.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/14/2018] [Accepted: 02/18/2018] [Indexed: 10/17/2022]
Affiliation(s)
- J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain.
| | - J Pérez-Bárcena
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut de Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
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Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma 2018; 35:889-906. [PMID: 29212411 PMCID: PMC5865621 DOI: 10.1089/neu.2017.5371] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.
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Affiliation(s)
- Raquel C. Gardner
- Department of Neurology, University of California San Francisco, and San Francisco VA Medical Center, San Francisco, California
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mt. Sinai, New York, New York
| | - Molly Rose Morrissey
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Geoffrey T. Manley
- University of California San Francisco Weill Institute for Neurosciences, San Francisco, California
- Department of Neurosurgery, Brain and Spinal Injury Center, University of California San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California
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Albrecht JS, Peters ME, Smith GS, Rao V. Anxiety and Posttraumatic Stress Disorder Among Medicare Beneficiaries After Traumatic Brain Injury. J Head Trauma Rehabil 2018; 32:178-184. [PMID: 28476057 DOI: 10.1097/htr.0000000000000266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate rates of anxiety and posttraumatic stress disorder (PTSD) diagnoses after traumatic brain injury (TBI) among Medicare beneficiaries, quantify the increase in rates relative to the pre-TBI period, and identify risk factors for diagnosis of anxiety and PTSD. PARTICIPANTS A total of 96 881 Medicare beneficiaries hospitalized with TBI between June 1, 2006 and May 31, 2010. DESIGN Retrospective cohort study. MEASURES Diagnosis of anxiety (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 300.0x) and/or PTSD (ICD-9-CM code 309.81). RESULTS After TBI, 16 519 (17%) beneficiaries were diagnosed with anxiety and 269 (0.3%) were diagnosed with PTSD. Rates of anxiety and PTSD diagnoses were highest in the first 5 months post-TBI and decreased over time. Pre-TBI diagnosis of anxiety disorder was significantly associated with post-TBI anxiety (risk ratio, 3.55; 95% confidence interval, 3.42-3.68) and pre-TBI diagnosis of PTSD was significantly associated with post-TBI PTSD (risk ratio 70.09; 95% confidence interval 56.29-111.12). CONCLUSION This study highlights the increased risk of anxiety and PTSD after TBI. Routine screening for anxiety and PTSD, especially during the first 5 months after TBI, may help clinicians identify these important and treatable conditions, especially among patients with a history of psychiatric illness.
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Affiliation(s)
- Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore (Drs Albrecht and Smith); Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Drs Peters and Rao); and Shock, Trauma and Anesthesiology Research-Organized Research Center, National Study Center for Trauma and Emergency Medical Services, University of Maryland, College Park (Dr Smith)
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Huang JL, Woehrle TA, Conway P, McCarty CA, Eyer MM, Eyer SD. Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin. Eur J Trauma Emerg Surg 2018. [DOI: 10.1007/s00068-018-0924-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Increased Rates of Mild Traumatic Brain Injury Among Older Adults in US Emergency Departments, 2009-2010. J Head Trauma Rehabil 2018; 31:E1-7. [PMID: 26479396 DOI: 10.1097/htr.0000000000000190] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate rates of emergency department (ED) visits for mild traumatic brain injury (TBI) among older adults. We defined possible mild TBI cases to assess underdiagnoses. DESIGN Cross-sectional. SETTING National sample of ED visits in 2009-2010 captured by the National Hospital Ambulatory Medical Care Survey. PARTICIPANTS Aged 65 years and older. MEASUREMENTS Mild TBI defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes (800.0x-801.9x, 803.xx, 804.xx, 850.xx-854.1x, 950.1x-950.3x, 959.01) and a Glasgow Coma Scale score of 14 or more or missing, excluding those admitted to the hospital. Possible mild TBI was defined similarly among those without mild TBI and with a fall or motor vehicle collision as cause of injury. We calculated rates of mild TBI and examined factors associated with a diagnosis of mild TBI. RESULTS Rates of ED visits for mild TBI were 386 per 100 000 among those aged 65 to 74 years, 777 per 100 000 among those aged 75 to 84 years, and 1205 per 100 000 among those older than 84 years. Rates for women (706/100 000) were higher than for men (516/100 000). Compared with a possible mild TBI, a diagnosis of mild TBI was more likely in the West (odds ratio = 2.31; 95% confidence interval, 1.02-5.24) and less likely in the South/Midwest (odds ratio = 0.52; 95% confidence interval, 0.29-0.96) than in the Northeast. CONCLUSIONS This study highlights an upward trend in rates of ED visits for mild TBI among older adults.
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Risk of Stroke Among Older Medicare Antidepressant Users With Traumatic Brain Injury. J Head Trauma Rehabil 2018; 32:E42-E49. [PMID: 27022963 DOI: 10.1097/htr.0000000000000231] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the risk of stroke associated with new antidepressant use among older adults with traumatic brain injury (TBI). PARTICIPANTS A total of 64 214 Medicare beneficiaries aged 65 years or older meeting inclusion criteria and hospitalized with a TBI during 2006 to 2010. DESIGN New user design. Generalized estimating equations were used to estimate the relative risks (RRs) of stroke. MAIN MEASURES Primary exposure was new antidepressant use following TBI identified through Medicare part D claims. The primary outcome was stroke following TBI. Ischemic and hemorrhagic strokes were secondary outcomes. RESULTS A total of 20 859 (32%) beneficiaries used an antidepressant at least once following TBI. Selective serotonin reuptake inhibitors accounted for the majority of antidepressant use. Selective serotonin reuptake inhibitor use was associated with an increased risk of hemorrhagic stroke (RR, 1.26; 95% confidence interval [CI], 1.06-1.50) but not ischemic stroke (RR, 1.04; 95% CI, 0.94-1.15). The selective serotonin reuptake inhibitors escitalopram (RR, 1.33; 95% CI, 1.02-1.74) and sertraline (RR, 1.46; 95% CI, 1.10-1.94) were associated with an increase in the risk of hemorrhagic stroke. CONCLUSION Findings from this study will aid prescribers in choosing appropriate antidepressants to treat depression in older adults with TBI.
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Khokhar B, Simoni-Wastila L, Slejko JF, Perfetto E, Zhan M, Smith GS. In-Hospital Mortality Following Traumatic Brain Injury Among Older Medicare Beneficiaries, Comparing Statin Users With Nonusers. J Pharm Technol 2017; 33:225-236. [PMID: 29607441 DOI: 10.1177/8755122517735656] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Traumatic brain injury (TBI) is a significant public health concern for older adults. Small-scale human studies have suggested pre-TBI statin use is associated with decreased in-hospital mortality following TBI, highlighting the need for large-scale translational research. Objective To investigate the relationship between pre-TBI statin use and in-hospital mortality following TBI. Methods A retrospective study of Medicare beneficiaries 65 and older hospitalized with a TBI during 2006 to 2010 was conducted to assess the impact of pre-TBI statin use on in-hospital mortality following TBI. Exposure of interest included atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Beneficiaries were classified as current, recent, past, and nonusers of statins prior to TBI. The outcome of interest was in-hospital mortality. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs) comparing current, recent, and prior statin use to nonuse. Results Most statin users were classified as current users (90%). Current atorvastatin (OR = 0.88; 95% = CI 0.82, 0.96), simvastatin (OR = 0.84; 95% CI = 0.79, 0.91), and rosuvastatin (OR = 0.79; 95% CI = 0.67, 0.94) use were associated with a significant decrease in the risk of in-hospital mortality following TBI. Conclusions In addition to being the most used statins, current use of atorvastatin, rosuvastatin, and simvastatin was associated with a significant decrease in in-hospital mortality following TBI among older adults. Future research must include clinical trials to help exclude the possibility of a healthy user effect in order to better understand the impact of statin use on in-hospital mortality following TBI.
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Affiliation(s)
- Bilal Khokhar
- General Dynamics Health Solutions, Defense and Veterans Brain Injury Center, Silver Spring, MD, USA
| | | | | | - Eleanor Perfetto
- University of Maryland, Baltimore, MD, USA.,National Health Council, Washington, DC, USA
| | - Min Zhan
- University of Maryland, Baltimore, MD, USA
| | - Gordon S Smith
- University of Maryland, Baltimore, MD, USA.,West Virginia University, Morgantown, WV, USA
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Schumacher R, Müri RM, Walder B. Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review. Curr Neurol Neurosci Rep 2017; 17:92. [PMID: 28986740 DOI: 10.1007/s11910-017-0801-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond. RECENT FINDINGS The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.
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Affiliation(s)
- Rahel Schumacher
- Department of Neurology, University Neurorehabilitation, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - René M Müri
- Department of Neurology, University Neurorehabilitation, Inselspital, University Hospital Bern, Freiburgstrasse 10, 3010, Bern, Switzerland
- Gerontechnology and Rehabilitation Group, University of Bern, Bern, Switzerland
| | - Bernhard Walder
- Division of Anaesthesiology, University Hospitals of Geneva, Geneva, Switzerland
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Wong H, Lovett N, Curry N, Shah K, Stanworth SJ. Antithrombotics in trauma: management strategies in the older patients. J Blood Med 2017; 8:165-174. [PMID: 29042825 PMCID: PMC5633276 DOI: 10.2147/jbm.s125209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The ageing population has resulted in a change in the demographics of trauma, and older adult trauma now accounts for a growing number of trauma admissions. The management of older adult trauma can be particularly challenging, and exhibits differences to that of the younger age groups affected by trauma. Frailty syndromes are closely related with falls, which are the leading cause of major trauma in older adults. Comorbid disease and antithrombotic use are more common in the older population. Physiological changes that occur with ageing can alter the expected clinical presentation of older persons after injury and their susceptibility to injury. Following major trauma, definitive control of hemorrhage remains essential for improving outcomes. In the initial assessment of an injured patient, it is important to consider whether the patient is taking anticoagulants or antiplatelets and if measures to promote hemostasis such as reversal are indicated. After hemostasis is achieved and bleeding has stopped, longer-term decisions to recommence antithrombotic agents can be challenging, especially in older people. In this review, we discuss one aspect of management for the older trauma patients in greater detail, that is, acute and longer-term management of antithrombotic therapy. As we consider the health needs of an ageing population, rise in elderly trauma and increasing use of antithrombotic therapy, the need for research in this area becomes more pressing to establish best practice and evidence-based care.
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Affiliation(s)
- Henna Wong
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust.,Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme
| | - Nicola Lovett
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust
| | - Nicola Curry
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust
| | - Ku Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme
| | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust.,Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme.,Department of Haematology, NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Khokhar B, Simoni-Wastila L, Slejko JF, Perfetto E, Zhan M, Smith GS. Patterns of Statin Use in Older Medicare Beneficiaries With Traumatic Brain Injury. J Pharm Technol 2017; 33:156-166. [PMID: 29577114 PMCID: PMC5863738 DOI: 10.1177/8755122517710671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In addition to lowering lipids, statins also may be beneficial for older adults sustaining a traumatic brain injury (TBI), as statin use prior to and following trauma may decrease mortality following injury. However, despite statins' potential to reduce mortality, there is limited research regarding statin use among older adults. OBJECTIVE To characterize and investigate factors associated with statin use among older adults with TBI. METHODS A retrospective drug utilization study was used to characterize statin use among Medicare beneficiaries 65 and older hospitalized with a TBI during 2006 to 2010 and with continuous Medicare Parts A, B, and D coverage 6 months prior and 12 months following TBI. Logistic regression was used to investigate the factors associated with statin use. The exposure of interest was statin use prior to and following TBI. RESULTS Of the 75 698 beneficiaries included in the study, 37 874 (~50%) of beneficiaries used a statin at least once during the study period. The most common statin used was simvastatin, while fluvastatin was the least used statin. Statin users were more likely to have cardiovascular diseases when compared to nonusers. Hyperlipidemia was a major factor associated with statin use and had the greatest impact on statin use compared to nonuse (odds ratio = 9.54; 95% confidence interval = 9.07, 10.03). CONCLUSIONS This national sample of older adults with TBI suggests that statins are commonly used. Future studies must next examine the impact of statin use on mortality and secondary injury in order to shape pharmacological therapy guidelines following TBI.
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Affiliation(s)
| | | | | | - Eleanor Perfetto
- University of Maryland, Baltimore, MD,
USA
- National Health Council, Washington, DC,
USA
| | - Min Zhan
- University of Maryland, Baltimore, MD,
USA
| | - Gordon S. Smith
- University of Maryland, Baltimore, MD,
USA
- West Virginia University, Morgantown,
WV, USA
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Nielsen PB, Larsen TB, Skjøth F, Lip GYH. Outcomes Associated With Resuming Warfarin Treatment After Hemorrhagic Stroke or Traumatic Intracranial Hemorrhage in Patients With Atrial Fibrillation. JAMA Intern Med 2017; 177:563-570. [PMID: 28241151 PMCID: PMC5470390 DOI: 10.1001/jamainternmed.2016.9369] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE The increase in the risk for bleeding associated with antithrombotic therapy causes a dilemma in patients with atrial fibrillation (AF) who sustain an intracranial hemorrhage (ICH). A thrombotic risk is present; however, a risk for serious harm associated with resumption of anticoagulation therapy also exists. OBJECTIVE To investigate the prognosis associated with resuming warfarin treatment stratified by the type of ICH (hemorrhagic stroke or traumatic ICH). DESIGN, SETTING, AND PARTICIPANTS This nationwide observational cohort study included patients with AF who sustained an incident ICH event during warfarin treatment from January 1, 1998, through February 28, 2016. Follow-up was completed April 30, 2016. Resumption of warfarin treatment was evaluated after hospital discharge. EXPOSURES No oral anticoagulant treatment or resumption of warfarin treatment, included as a time-dependent exposure. MAIN OUTCOMES AND MEASURES One-year observed event rates per 100 person-years were calculated, and treatment strategies were compared using time-dependent Cox proportional hazards regression models with adjustment for age, sex, length of hospital stay, comorbidities, and concomitant medication use. RESULTS A total of 2415 patients with AF in this cohort (1481 men [61.3%] and 934 women [38.7%]; mean [SD] age, 77.1 years [9.1 years]) sustained an ICH event. Of these events, 1325 were attributable to hemorrhagic stroke and 1090 were secondary to trauma. During the first year, 305 patients with a hemorrhagic stroke (23.0%) died, whereas 210 in the traumatic ICH group (19.3%) died. Among patients with hemorrhagic stroke, resuming warfarin therapy was associated with a lower rate of ischemic stroke or systemic embolism (SE) (adjusted hazard ratio [AHR], 0.49; 95% CI, 0.24-1.02) and an increased rate of recurrent ICH (AHR, 1.31; 95% CI, 0.68-2.50) compared with not resuming warfarin therapy, but these differences did not reach statistical significance. For patients with traumatic ICH, resuming warfarin therapy also was associated with a lower rate of ischemic stroke or SE (AHR, 0.40; 95% CI, 0.15-1.11); however, in contrast to patients with hemorrhagic stroke, therapy resumption was associated with a significantly lower rate of recurrent ICH (AHR, 0.45; 95% CI, 0.26-0.76). A reduction in mortality was associated with resuming warfarin therapy among patients with hemorrhagic stroke (AHR, 0.51; 95% CI, 0.37-0.71) and those with traumatic ICH (AHR, 0.35; 95% CI, 0.23-0.52). CONCLUSIONS AND RELEVANCE Resumption of warfarin therapy after spontaneous hemorrhagic stroke in patients with AF was associated with a lower rate of ischemic events and a higher rate of recurrent ICH. Among patients with a traumatic ICH, a similar lower rate of ischemic events was found; however, a lower relative risk for recurrent ICH despite resuming warfarin treatment was also revealed.
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Affiliation(s)
- Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark2Department of Cardiology, Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark2Department of Cardiology, Atrial Fibrillation Study Group, Aalborg University Hospital, Aalborg, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark3Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark4Institute for Cardiovascular Sciences, University of Birmingham, City Hospital, Birmingham, England
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Canavero I, Cavallini A, Sacchi L, Quaglini S, Arnò N, Perrone P, DeLodovici ML, Marcheselli S, Micieli G. Safely Addressing Patients with Atrial Fibrillation to Early Anticoagulation after Acute Stroke. J Stroke Cerebrovasc Dis 2016; 26:7-18. [PMID: 27614403 DOI: 10.1016/j.jstrokecerebrovasdis.2016.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/25/2016] [Accepted: 08/12/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It has been widely reported that anticoagulants (ACs) are underused for primary and secondary prevention of ischemic stroke in patients with atrial fibrillation (AFib). Furthermore, precise evidence-based guidelines about the best timing for AC initiation after acute stroke are currently lacking. METHODS AND RESULTS In this retrospective, observational study, we analyzed prescription trends in AFib patients with acute ischemic stroke who were hospitalized in four neurologic stroke units of our region (Lombardia, Italy). In-hospital antithrombotic prescription was performed in highly heterogeneous patterns. A prestroke treatment with AC was the leading factor enhancing AC prescription during hospitalization. The other factors promoting AC were male gender, younger age, lower prestroke disability and stroke severity, and smaller stroke volumes. AFib subtype influenced AC prescription only in AC-naïve patients. Interestingly, Congestive heart failure, Hypertension, Age higher than 75 years, Diabetes, previous Stroke or TIA or thromboembolism, Vascular disease, Age 64-75 years, female Sex (CHA2DS2-VASc) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs and alcohol (HAS-BLED) scores were not associated with AC prescription. However, patients who were treated with AC, including early treatment (<48 hours), showed a low rate of bleeding. CONCLUSIONS Our findings potentially suggest that, although apparently neglecting the common risk stratification tools, our neurologists were able to select the more suitable candidates for prompt AC treatment. Further studies are needed to develop new scoring systems to aid ischemic and hemorrhagic risk estimation in the secondary prevention of stroke.
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Affiliation(s)
- Isabella Canavero
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy.
| | - Anna Cavallini
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Natale Arnò
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
| | - Patrizia Perrone
- Department of Neurosciences, Neurology Unit, "Ospedale Civile", Legnano, Italy
| | - Maria Luisa DeLodovici
- Stroke Unit, Department of Neurology, "Fondazione Macchi-Ospedale di Circolo", Insubria University, Varese, Italy
| | - Simona Marcheselli
- Emergency Neurology and Stroke Unit, "Istituto Clinico Humanitas", Milan, Italy
| | - Giuseppe Micieli
- Department of Emergency Neurology and Stroke Unit, National Neurological Institute "Casimiro Mondino" IRCCS, Pavia, Italy
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Matsushima K, Inaba K, Cho J, Mohammed H, Herr K, Leichtle S, Zada G, Demetriades D. Therapeutic anticoagulation in patients with traumatic brain injury. J Surg Res 2016; 205:186-91. [PMID: 27621017 DOI: 10.1016/j.jss.2016.06.042] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/02/2016] [Accepted: 06/14/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Therapeutic anticoagulation (TAC) is often required in trauma patients for various indications. However, it remains unknown whether TAC can be safely initiated in the postinjury period for patients with traumatic brain injury (TBI). The purpose of this study was to evaluate the safety of TAC in TBI patients. MATERIALS AND METHODS We conducted a 7-y retrospective study. All TBI patients who received TAC within 60 d postinjury were included. In addition to patient and injury characteristics, detailed information regarding TAC was collected. The primary outcome was the incidence of neurologic deterioration or progression of hemorrhagic TBI on repeat head computed tomography (CT) after initiation of TAC. Univariate and multivariate analyses were used to identify factors associated with progression of hemorrhagic TBI after TAC. RESULTS A total of 3355 TBI patients were identified. Of those, 72 patients (2.1%) received TAC. Median age, 59; 76.4% male; median Injury Severity Score, 19; median admission Glasgow Coma Scale, 14; and median Rotterdam score on the initial head CT, 3. Although atrial fibrillation was the most common preinjury indication for TAC, venous thromboembolism was the most common postinjury indication. The median postinjury time of initiation of TAC was 9 d. Intravenous heparin infusion was the most commonly used agent for TAC (70.8%). None of our study patients developed any signs of neurologic deterioration due to TAC. Progression of hemorrhagic TBI on repeat head CT was observed in six patients. In a multiple logistic regression model, aged ≥65 y was significantly associated with progression of hemorrhagic TBI after TAC (odds ratio, 15.2; 95% confidence interval, 1.1-212.7; P = 0.04). CONCLUSIONS This study shows preliminary data regarding TAC initiated in patients with TBI. Further prospective study is warranted to determine the risks and benefits of TAC in this specific group of patients.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California.
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Jayun Cho
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Hussan Mohammed
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Keith Herr
- Department of Radiology, University of Southern California, Los Angeles, California
| | - Stefan Leichtle
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California, Los Angeles, California
| | - Demetrios Demetriades
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, California
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Ottosen TP, Grijota M, Hansen ML, Brandes A, Damgaard D, Husted SE, Johnsen SP. Use of Antithrombotic Therapy and Long-Term Clinical Outcome Among Patients Surviving Intracerebral Hemorrhage. Stroke 2016; 47:1837-43. [PMID: 27301947 DOI: 10.1161/strokeaha.116.012945] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/03/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE The effectiveness and safety of antithrombotic therapy (AT) among patients with a history of intracerebral hemorrhage remain uncertain. We therefore determined the prevalence of indication for AT among patients hospitalized with first-time intracerebral hemorrhage and examined the impact of subsequent AT use on the long-term clinical outcome. METHODS We performed a population-based cohort study using nationwide Danish medical registries. Patients with risk of thromboembolism surviving the first 30 days after hospitalization because of intracerebral hemorrhage were identified and followed up. We estimated the hazard ratio of all-cause death, thromboembolic events, or major bleeding according to use of AT. RESULTS We identified 6369 patients between 2005 and 2013. Among these patients, 2978 (47%) had indication for AT, and during the follow-up, (median: 2.3 year) 1281 (43%) died, 497 (17%) had a thromboembolic event, and 536 (18%) had major bleeding. Postdischarge use of oral anticoagulation therapy among patients with indication for oral anticoagulation therapy was associated with a significant lower risk of death (adjusted hazard ratio, 0.59; 95% confidence interval, 0.43-0.82) and thromboembolic events (adjusted hazard ratio 0.58; 95% confidence interval, 0.35-0.97) and no increased risk of major bleeding (adjusted hazard ratio 0.65; 95% confidence interval, 0.41-1.02). In contrast, use of platelet inhibitors among patients with indication for platelet inhibitors was not related to statistically significantly improved clinical outcome. CONCLUSIONS Approximately 1 of 2 patients surviving intracerebral hemorrhage had a high risk of thromboembolism. Postdischarge use of oral anticoagulation therapy was associated with a lower risk of all-cause mortality and thromboembolic events and no increased risk of major bleeding.
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Affiliation(s)
- Tobias Pilgaard Ottosen
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.).
| | - Miriam Grijota
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.)
| | - Morten Lock Hansen
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.)
| | - Axel Brandes
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.)
| | - Dorte Damgaard
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.)
| | - Steen Elkjær Husted
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.)
| | - Søren Paaske Johnsen
- From the Department of Clinical Epidemiology (T.P.O., M.G., S.P.J.) and Department of Neurology (D.D.), Aarhus University Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark (M.L.H.); Department of Cardiology, Odense University Hospital, Denmark (A.B.); and Department of Medicine, Regional Hospital West Jutland, Herning, Denmark (S.E.H.)
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Goodman SG. Prior bleeding, future bleeding and stroke risk with oral anticoagulation in atrial fibrillation: What new lessons can ARISTOTLE teach us? Am Heart J 2016; 175:168-71. [PMID: 27179736 DOI: 10.1016/j.ahj.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/10/2016] [Indexed: 10/22/2022]
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Hopp S, Albert-Weissenberger C, Mencl S, Bieber M, Schuhmann MK, Stetter C, Nieswandt B, Schmidt PM, Monoranu CM, Alafuzoff I, Marklund N, Nolte MW, Sirén AL, Kleinschnitz C. Targeting coagulation factor XII as a novel therapeutic option in brain trauma. Ann Neurol 2016; 79:970-82. [PMID: 27043916 PMCID: PMC5074329 DOI: 10.1002/ana.24655] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 03/17/2016] [Accepted: 03/27/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Traumatic brain injury is a major global public health problem for which specific therapeutic interventions are lacking. There is, therefore, a pressing need to identify innovative pathomechanism-based effective therapies for this condition. Thrombus formation in the cerebral microcirculation has been proposed to contribute to secondary brain damage by causing pericontusional ischemia, but previous studies have failed to harness this finding for therapeutic use. The aim of this study was to obtain preclinical evidence supporting the hypothesis that targeting factor XII prevents thrombus formation and has a beneficial effect on outcome after traumatic brain injury. METHODS We investigated the impact of genetic deficiency of factor XII and acute inhibition of activated factor XII with a single bolus injection of recombinant human albumin-fused infestin-4 (rHA-Infestin-4) on trauma-induced microvascular thrombus formation and the subsequent outcome in 2 mouse models of traumatic brain injury. RESULTS Our study showed that both genetic deficiency of factor XII and an inhibition of activated factor XII in mice minimize trauma-induced microvascular thrombus formation and improve outcome, as reflected by better motor function, reduced brain lesion volume, and diminished neurodegeneration. Administration of human factor XII in factor XII-deficient mice fully restored injury-induced microvascular thrombus formation and brain damage. INTERPRETATION The robust protective effect of rHA-Infestin-4 points to a novel treatment option that can decrease ischemic injury after traumatic brain injury without increasing bleeding tendencies. Ann Neurol 2016;79:970-982.
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Affiliation(s)
- Sarah Hopp
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany.,Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - Christiane Albert-Weissenberger
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany.,Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - Stine Mencl
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Michael Bieber
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center (DZHI), University Hospital of Würzburg, Würzburg, Germany
| | | | - Christian Stetter
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
| | - Bernhard Nieswandt
- Rudolf Virchow Center, German Research Society Research Center for Experimental Biomedicine, Julius Maximilian University, Würzburg, Germany
| | - Peter M Schmidt
- CSL Limited, Bio21 Molecular Science and Biotechnology Institute, Parkville, Victoria, Australia
| | - Camelia-Maria Monoranu
- Institute of Pathology, Department of Neuropathology, Comprehensive Cancer Center Mainfranken, Julius Maximilian University, Würzburg, Germany
| | - Irina Alafuzoff
- Department of Immunology, Uppsala University, Uppsala, Sweden.,Department of Pathology, Uppsala University, Uppsala, Sweden
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anna-Leena Sirén
- Department of Neurosurgery, University Hospital of Würzburg, Würzburg, Germany
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46
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Schwarzmaier SM, de Chaumont C, Balbi M, Terpolilli NA, Kleinschnitz C, Gruber A, Plesnila N. The Formation of Microthrombi in Parenchymal Microvessels after Traumatic Brain Injury Is Independent of Coagulation Factor XI. J Neurotrauma 2016; 33:1634-44. [PMID: 26886854 DOI: 10.1089/neu.2015.4173] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Microthrombus formation and bleeding worsen the outcome after traumatic brain injury (TBI). The aim of the current study was to characterize these processes in the brain parenchyma after experimental TBI and to determine the involvement of coagulation factor XI (FXI). C57BL/6 mice (n = 101) and FXI-deficient mice (n = 15) were subjected to controlled cortical impact (CCI). Wild-type mice received an inhibitory antibody against FXI (14E11) or control immunoglobulin G 24 h before or 30 or 120 min after CCI. Cerebral microcirculation was visualized in vivo by 2-photon microscopy 2-3 h post-trauma and histopathological outcome was assessed after 24 h. TBI induced hemorrhage and microthrombus formation in the brain parenchyma (p < 0.001). Inhibition of FXI activation or FXI deficiency did not reduce cerebral thrombogenesis, lesion volume, or hemispheric swelling. However, it also did not increase intracranial hemorrhage. Formation of microthrombosis in the brain parenchyma after TBI is independent of the intrinsic coagulation cascade since it was not reduced by inhibition of FXI. However, since targeting FXI has well-established antithrombotic effects in humans and experimental animals, inhibition of FXI could represent a reasonable strategy for the prevention of deep venous thrombosis in immobilized patients with TBI.
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Affiliation(s)
- Susanne M Schwarzmaier
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland .,2 Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center , Munich, Germany .,3 Department of Anesthesiology, University of Munich Medical Center , Munich, Germany
| | - Ciaran de Chaumont
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland
| | - Matilde Balbi
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland .,2 Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center , Munich, Germany
| | - Nicole A Terpolilli
- 2 Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center , Munich, Germany
| | | | - Andras Gruber
- 5 Departments of Biomedical Engineering and Medicine, Knight Cardiovascular Institute, Oregon Health and Science University , School of Medicine, Portland, Oregon
| | - Nikolaus Plesnila
- 1 Department of Neurodegeneration, Royal College of Surgeons in Ireland (RCSI) , Dublin, Ireland .,2 Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center , Munich, Germany .,6 SyNergy, Munich Cluster for Systems Neurology , Munich, Germany
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47
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Abstract
Older patients with atrial fibrillation have an increased risk of stroke and systemic embolism compare with younger patients. For most patients, oral anticoagulation remains the most effective way to reduce this risk. Although vitamin K antagonists have been used for decades, the more recent development of non-vitamin K-dependent oral anticoagulants provides clinicians with a broader selection of anticoagulants for stroke prevention in older patients with AF. This article discusses stroke risk-stratification tools for clinical decision making, reviews pharmacologic options for the prevention of stroke, and highlights several practical considerations to the use of these agents in older adults.
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Affiliation(s)
- Karli Edholm
- Division of General Internal Medicine, University of Utah School of Medicine, 5R218, Salt Lake City, UT 84132, USA
| | - Nathan Ragle
- Division of General Internal Medicine, University of Utah School of Medicine, 5R218, Salt Lake City, UT 84132, USA
| | - Matthew T Rondina
- Program in Molecular Medicine, University of Utah School of Medicine, 15 North 2030 East Rm 4145, Salt Lake City, UT 84112, USA.
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48
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The risks of thromboembolism vs. recurrent gastrointestinal bleeding after interruption of systemic anticoagulation in hospitalized inpatients with gastrointestinal bleeding: a prospective study. Am J Gastroenterol 2015; 110:328-35. [PMID: 25512338 DOI: 10.1038/ajg.2014.398] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/01/2014] [Accepted: 11/07/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Anticoagulants carry a significant risk of gastrointestinal bleeding (GIB). Data regarding the safety of anticoagulation continuation/cessation after GIB are limited. We sought to determine the safety and risk of continuation of anticoagulation after GIB. METHODS We conducted a prospective observational cohort study on consecutive patients admitted to the hospital who had GIB while on systemic anticoagulation. Patients were classified into two groups at hospital discharge after GIB: those who resumed anticoagulation and those who had anticoagulation discontinued. Patients in both groups were contacted by phone 90 days after discharge to determine the following outcomes: (i) thromboembolic events, (ii) hospital readmissions related to GIB, and (iii) mortality. Univariate and multivariate Cox proportional hazards were used to determine factors associated with thrombotic events, rebleeding, and death. RESULTS We identified 197 patients who developed GIB while on systemic anticoagulation (n=145, 74% on warfarin). Following index GIB, anticoagulation was discontinued in 76 patients (39%) at discharge. In-hospital transfusion requirements, need for intensive care unit care, and etiology of GIB were similar between the two groups. During the follow-up period, 7 (4%) patients suffered a thrombotic event and 27 (14%) patients were readmitted for GIB. Anticoagulation continuation was independently associated on multivariate regression with a lower risk of major thrombotic episodes within 90 days (hazard ratio (HR)=0.121, 95% confidence interval (CI)=0.006-0.812, P=0.03). Patients with any malignancy at time of GIB had an increased risk of thromboembolism in follow-up (HR=6.1, 95% CI=1.18-28.3, P=0.03). Anticoagulation continuation at discharge was not significantly associated with an increased risk of recurrent GIB at 90 days (HR=2.17, 95% CI=0.861-6.67, P=0.10) or death within 90 days (HR=0.632, 95% CI=0.216-1.89, P=0.40). CONCLUSIONS Restarting anticoagulation at discharge after GIB was associated with fewer thromboembolic events without a significantly increased risk of recurrent GIB at 90 days. The benefits of continuing anticoagulation at discharge may outweigh the risks of recurrent GIB.
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