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Karamian A, Seifi A, Lucke-Wold B. Effects of preinjury oral anticoagulants on the outcomes of traumatic brain injury in elderly patients: a systematic review and meta-analysis. Brain Inj 2024:1-15. [PMID: 39140511 DOI: 10.1080/02699052.2024.2392163] [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: 03/18/2024] [Revised: 08/01/2024] [Accepted: 08/09/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND With the increasing cases of TBI cases in the elderly population taking anticoagulants for comorbidities, there is a need to better understand the safety of new anticoagulants and how to manage anticoagulated TBI patients. METHODS A meta-analysis using a random-effect model was conducted to compare the effect of preinjury use of DOACs and VKAs on the outcomes following TBI. RESULTS From 1951 studies, 49 studies with a total sample size of 15,180 met our inclusion criteria. Our meta-analysis showed no difference between preinjury use of DOACs or VKAs on ICH progression, in-hospital delayed ICH, delayed ICH at follow-up, and in-hospital mortality, but using DOACs was associated with a lower risk of immediate ICH (OR = 0.58; 95% CI = [0.42; 0.79]; p < 0.01) and neurosurgical interventions (OR = 0.59; 95% CI = [0.42; 0.82]; p < 0.01) compared to VKAs. Moreover, patients on DOACs experienced shorter length of stay in the hospital than those on VKAs (OR = -0.42; 95% CI = [-0.78; -0.07]; p = 0.02). CONCLUSION We found a lower risk of immediate ICH and surgical interventions as well as a shorter hospital stay in patients receiving DOACs compared to VKA users before the head injury.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, Texas, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
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Sakkas A, Weiß C, Wilde F, Ebeling M, Thiele OC, Mischkowski RA, Pietzka S. Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit. Eur J Trauma Emerg Surg 2024; 50:157-172. [PMID: 36707437 DOI: 10.1007/s00068-023-02228-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings. METHODS This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis. RESULTS A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant. CONCLUSION According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany.
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | | | | | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany
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Perkins L, Adams L, Lerner D, Santorelli J, Smith AM, Kobayashi L. Predictors of direct oral anticoagulant concentrations in the trauma population. Trauma Surg Acute Care Open 2024; 9:e001208. [PMID: 38274020 PMCID: PMC10806470 DOI: 10.1136/tsaco-2023-001208] [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] [Indexed: 01/27/2024] Open
Abstract
Introduction Direct oral anticoagulant (DOAC) use is becoming more prevalent in patients presenting after trauma. We sought to identify the prevalence and predictors of subtherapeutic and therapeutic DOAC concentrations and hypothesized that increased anti-Xa levels would correlate with increased risk of bleeding and other poor outcomes. Methods A retrospective cohort study of all trauma patients on apixaban or rivaroxaban admitted to a level 1 trauma center between January 2015 and July 2021 was performed. Patients were excluded if they did not have a DOAC-specific anti-Xa level at presentation. Therapeutic levels were defined as an anti-Xa of 50 ng/mL to 250 ng/mL for rivaroxaban and 75 ng/mL to 250 ng/mL for apixaban. Linear regression was used to identify correlations between study variables and anti-Xa level, and binomial logistic regression was used to test the association of anti-Xa level with outcomes. Results There were 364 trauma patients admitted during the study period who were documented to be on apixaban or rivaroxaban. Of these, 245 patients had anti-Xa levels measured at admission. The population was 53% woman, with median age of 78 years, and median Injury Severity Score of 5. In total, 39% of patients had therapeutic and 20% had supratherapeutic anti-Xa levels. Female sex, increased age, decreased height and weight, and lower estimated creatinine clearance were associated with higher anti-Xa levels at admission. There was no correlation between anti-Xa level and the need for transfusion or reversal agent administration, admission diagnosis of intracranial hemorrhage (ICH), progression of ICH, hospital length of stay, or mortality. Conclusions Anti-Xa levels in trauma patients on DOACs vary widely; female patients who are older, smaller, and have decreased kidney function present with higher DOAC-specific anti-Xa levels after trauma. We were unable to detect an association between anti-Xa levels and clinical outcomes. Level of evidence III-Prognostic and Epidemiological.
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Affiliation(s)
- Louis Perkins
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Laura Adams
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Dmitri Lerner
- Department of Pharmacy, University of California San Diego, San Diego, California, USA
| | - Jarrett Santorelli
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Alan M Smith
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
| | - Leslie Kobayashi
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California San Diego, San Diego, California, USA
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Sakkas A, Weiß C, Wilde F, Ebeling M, Scheurer M, Thiele OC, Mischkowski RA, Pietzka S. Justification of Indication for Cranial CT Imaging after Mild Traumatic Brain Injury According to the Current National Guidelines. Diagnostics (Basel) 2023; 13:diagnostics13111826. [PMID: 37296677 DOI: 10.3390/diagnostics13111826] [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: 04/21/2023] [Revised: 05/14/2023] [Accepted: 05/21/2023] [Indexed: 06/12/2023] Open
Abstract
The primary aim was to evaluate the compliance of cranial CT indication with the national guideline-based decision rules in patients after mTBI. The secondary aim was to determine the incidence of CT pathologies among justified and unjustified CT scans and to investigate the diagnostic value of these decision rules. This is a retrospective, single-center study on 1837 patients (mean age = 70.7 years) referred to a clinic of oral and maxillofacial surgery following mTBI over a five-year period. The current national clinical decision rules and recommendations for mTBI were retrospectively applied to calculate the incidence of unjustified CT imaging. The intracranial pathologies among the justified and unjustified CT scans were presented using descriptive statistical analysis. The performance of the decision rules was ascertained by calculating the sensitivity, specificity, and predictive values. A total of 123 intracerebral lesions were radiologically detected in 102 (5.5%) of the study patients. Most (62.1%) of the CT scans strictly complied with the guideline recommendations, and 37.8% were not justified and likely avoidable. A significantly higher incidence of intracranial pathology was observed in patients with justified CT scans compared with patients with unjustified CT scans (7.9% vs. 2.5%, p < 0.0001). Patients with loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures presented pathologic CT findings more frequently (p < 0.05). The decision rules identified CT pathologies with 92.28% sensitivity and 39.08% specificity. To conclude, compliance with the national decision rules for mTBI was low, and more than a third of the CT scans performed were identified as "likely avoidable". A higher incidence of pathologic CT findings was detected in patients with justified cranial CT imaging. The investigated decision rules showed a high sensitivity but low specificity for predicting CT pathologies.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, 68167 Mannheim, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Mario Scheurer
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Oliver Christian Thiele
- Department of Oral and Plastic Maxillofacial Surgery, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | - Robert Andreas Mischkowski
- Department of Oral and Plastic Maxillofacial Surgery, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
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Sakkas A, Weiß C, Ebeling M, Wilde F, Pietzka S, Mohammad Q, Thiele OC, Mischkowski RA. Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis. J Clin Med 2023; 12:jcm12103563. [PMID: 37240668 DOI: 10.3390/jcm12103563] [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: 04/21/2023] [Revised: 05/08/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, 69167 Mannheim, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Qasim Mohammad
- Institute for Diagnostic and Interventional Radiology, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | - Oliver Christian Thiele
- Department of Cranio-Maxillo-Facial-Surgery, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
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Flaherty S, Biswas S, Watts DD, Wilson NY, Shen Y, Garland JM, Wyse RJ, Lieser MJ, Duane TM, Offner PJ, Love JD, Shillinglaw WC, Hunt DL, Gauny RW, Fakhry SM, Curcio GJ, Gilligan D, Taylor DA, Hughes F, Barker RJ, Bissinger CM, Miller CJ, Harbour LF, Duane TM, Carrick MM, Lieser MJ, Flaherty S, Blair V, Perez J, Cervantes C, Hogan C, Ruiz CR, Tinti M, Romero CA, Jones KJ, Neeley T, Wright K, Dunne J, Eversley-Kelso T, Harte MA, Kline RA, Love JD, van Doorn E, Brock CM, Acuna DL, Shaddix JL, Rhodes H, Biswas S, Shillinglaw WC, Slivinski A, Offner PJ, Levine JH, Banton KL, Katubig B. Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use. Ann Emerg Med 2023; 81:364-374. [PMID: 36328853 DOI: 10.1016/j.annemergmed.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 07/20/2022] [Accepted: 08/02/2022] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE Evaluate the utility of routine rescanning of older, mild head trauma patients with an initial negative brain computed tomography (CT), who is on a preinjury antithrombotic (AT) agent by assessing the rate of delayed intracranial hemorrhage (dICH), need for surgery, and attributable mortality. METHODS Participating centers were trained and provided data collection instruments per institutional review board-approved protocols. Data were obtained from manual chart review and electronic medical record download. Adults ≥55 years seen at Level I/II Trauma Centers, between 2017 and 2019 with suspected head trauma, Glasgow Coma Scale 14 to 15, negative initial brain CT, and no other Abbreviated Injury Scale injuries >2 were identified, grouped by preinjury AT therapy (AT- or AT+) and compared on dICH rate, need for operative neurosurgical intervention, and attributable mortality using univariate analysis (α=.05). RESULTS A total of 2,950 patients from 24 centers were enrolled; 280 (9.5%) had a repeat brain CT. In those rescanned, the dICH rate was 15/126 (11.9%) for AT- and 6/154 (3.9%) in AT+. Assuming nonrescanned patients did not suffer clinically meaningful dICH, the dICH rate would be 15/2001 (0.7%) for AT- and 6/949 (0.6%) for AT+. No surgical operations were done for dICH. All-cause mortality was 9/2950 (0.3%) and attributable mortality was 1/2950 (0.03%). The attributable death was an AT+, dICH patient whose family declined intervention. CONCLUSION In older patients with an initial Glasgow Coma Scale of 14 to 15 and a negative initial brain CT scan, the dICH rate is low (<1%) and of minimal clinical consequence, regardless of AT use. In addition, no patient had operative neurosurgical intervention. Therefore, routine rescanning is not supported based on the results of this study.
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Affiliation(s)
| | | | - Dorraine D Watts
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Nina Y Wilson
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Yan Shen
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Jeneva M Garland
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Ransom J Wyse
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN
| | - Mark J Lieser
- Department of Trauma Surgery, Research Medical Center, Kansas City, MO
| | | | | | - Joseph D Love
- Department of Surgery, Regional Medical Center Bayonet Point, Hudson, FL
| | | | - Darrell L Hunt
- Department of Surgery, TriStar Skyline Medical Center, Nashville, TN
| | - Randy W Gauny
- Trauma Services, HCA Houston Healthcare Conroe, Conroe, TX
| | - Samir M Fakhry
- Center for Trauma and Acute Care Surgery Research, Clinical Services Group, HCA Healthcare, Nashville, TN.
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7
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Limited benefit of systematic head CT for mild traumatic brain injury in patients under antithrombotic therapy. J Neuroradiol 2023; 50:30-35. [PMID: 33636220 DOI: 10.1016/j.neurad.2021.02.004] [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: 06/27/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Mild traumatic brain injury (mTBI) in patients on antiplatelet (AP), anticoagulant (AC) or direct oral anticoagulant (DOAC) medication has become a systematic indication for head CT. However, the over-risk and impact of the intracranial hemorrhages (IH) detected with CT in this population remain unclear and need to be assessed. MATERIALS AND METHODS We prospectively assessed head CTs performed in adults taking AP/AC/DOAC referred after a mTBI to our Emergency Departments between September 2016 and January 2018. Frequency, type and severity of IH were described and frequency was analyzed as a function of treatment. RESULTS 840 patients were prospectively included. 58.9% were treated with AP, 23.7% with AC, 11.7% with DOAC and 5.7% with a combination of antithrombotic agents. The rate of IH detected with head CT was 5.8% (n...=...49), of which 81.6% (n...=...40) and 18.4% (n...=...9) with minor and intermediate severity respectively. No patient required surgical care and no death occurred. No statistically significant difference was found in treatment distribution between patients with or without IH (p...=...0.98). Among the patients who discontinued their antithrombotic treatment after mTBI, three experienced thrombotic events during the hospitalization. CONCLUSIONS Our results showed a low frequency and severity of IH in mTBI patients indifferently treated with AP, AC or DOAC, without secondary neurological deterioration, death or need of surgical care. Our study suggests the limited benefit of systematic CT head scan as a standard practice for the management of mTBI patients under antithrombotic therapy.
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Turcato G, Zaboli A, Bonora A, Ricci G, Zannoni M, Maccagnani A, Zorzi E, Pfeifer N, Brigo F. Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort. J Emerg Med 2023; 64:1-13. [PMID: 36658008 DOI: 10.1016/j.jemermed.2022.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/25/2022] [Accepted: 09/04/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED). OBJECTIVE This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI. METHODS A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED. RESULTS Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients. CONCLUSIONS Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Antonio Bonora
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giorgio Ricci
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Massimo Zannoni
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Antonio Maccagnani
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Elisabetta Zorzi
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
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ÇATAL Y, GÜNALP M, GENÇ S, OĞUZ AB, KOCA A, POLAT O. Do We Need to Repeat the Initially Normal Head Computerized Tomography for Patients with Mild Head Trauma Using Anticoagulant and/or Antiplatelet Therapy? KONURALP TIP DERGISI 2022. [DOI: 10.18521/ktd.1167329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: Patients using anticoagulant and/or antiplatelet (AC/AP) medications are at an increased risk of intracranial hemorrhage (ICH) subsequent to head trauma and current guidelines recommend a head computed tomography (CT) scan for these patients. There is a lack of consensus about management recommendations for mild head trauma patients on AC/AP treatment who had an initially normal head CT. The aim of this study was to determine the rate of delayed ICH after a 24-hour observation in patients with mild head trauma using AC/AP who had an initially normal head CT.
Method: Patients aged 18 and older, using AC/AP drugs with mild head trauma were included prospectively. Patients underwent head CT for suspected bleeding. A repeat CT scan was performed after a 24-hours observation period for the patients who had an initially normal head CT for detecting delayed intracranial hemorrhage.
Result: A total of 101 patients were included and, 57.4% (n=58) of the patients were female. Delayed ICH was detected in 2.9% (n=3) of the patients after a 24-hour observation. None of the patients with delayed ICH needed surgical treatment or further intervention. Delayed ICH was found in patients who used acetylsalicylic acid (n=1), dabigatran (n=1), and apixaban (n=1).
Conclusion: In patients with mild head trauma using AC/AP, delayed intracranial hemorrhage is rare and may be clinically insignificant. A repeat CT scanning after 24-hour observation may not be necessary for patients with mild head trauma using AC/AP therapy who had initially normal head CT.
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Affiliation(s)
- Yaşar ÇATAL
- Kayseri State Hospital, Department of Emergency Medicine
| | - Müge GÜNALP
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Sinan GENÇ
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Ahmet Burak OĞUZ
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Ayça KOCA
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Onur POLAT
- Ankara University School of Medicine, Department of Emergency Medicine
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10
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Bouget J, Jouhanny A, Soulat L, Oger E. Ground-level falls among nonagenarians: the impact of pre-injury antithrombotic therapy. Intern Emerg Med 2022; 17:1309-1319. [PMID: 35112277 DOI: 10.1007/s11739-021-02914-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/16/2021] [Indexed: 12/21/2022]
Abstract
Among nonagenarians admitted to our emergency department (ED) for ground-level falls, we assessed the impact of pre-injury antithrombotic (AT) treatment on the post-traumatic consequences, and identified risk factors for 1-month mortality. All eligible patients were consecutively included over an 18-month period. Head trauma was attested by reliable medical history, witnesses or recent external signs. Patient characteristics, post-traumatic consequences and outcomes were compared across patients with and without AT. Risk factors for 1-month mortality were assessed using multivariate logistic regression analyses. 1014 consecutive nonagenarians were analysed, 675 (66.6%) with AT and 339 (33.4%) without. Head trauma (n = 429, 42.3%) was significantly more frequent among patients with AT (49.2 vs 28.6%, p < 0.001). Intracranial hemorrhage (ICH, n = 43, 4.2%), mostly subdural hematomas (58%), were more frequently found among patients with AT (p < 0.015). At least one fracture was diagnosed for 23.9% of the population, mostly hip fractures, without any significant association with AT. At 1 month, 103 patients (10.2%) had died. The independent risk factors for 1-month mortality were: ICH associated with head trauma (OR = 5.9, 95% CI 2.5-14), Glasgow coma score ≤ 12 at admission (OR = 10; 95% CI 2.2-46), atrial fibrillation (OR = 2.2, 95% CI 1.4-3.4) and age ≥ 95 years (OR = 1.6, 95% CI 1.0-2.5). Our results support accurate and regular assessment of the benefit/risk ratio for antithrombotic treatment among elderly people at high risk for falls.
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Affiliation(s)
- Jacques Bouget
- Emergency Department, University Hospital, 35033, Rennes, France.
- University of Rennes, CHU Rennes, EA 7449 (Pharmacoepidemiology and Health Services Research) REPERES, University Hospital, F-35043, Rennes, France.
| | - Alexia Jouhanny
- Emergency Department, University Hospital, 35033, Rennes, France
| | - Louis Soulat
- Emergency Department, University Hospital, 35033, Rennes, France
| | - Emmanuel Oger
- University of Rennes, CHU Rennes, EA 7449 (Pharmacoepidemiology and Health Services Research) REPERES, University Hospital, F-35043, Rennes, France
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11
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Posti JP, Ruuskanen JO, Sipilä JOT, Luoto TM, Rautava P, Kytö V. Effect of Oral Anticoagulation and Adenosine Diphosphate Inhibitor Therapies on Short-term Outcome of Traumatic Brain Injury. Neurology 2022; 99:e1122-e1130. [PMID: 35764401 DOI: 10.1212/wnl.0000000000200834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Usage of oral anticoagulants (OAC) or adenosine diphosphate inhibitors (ADPi) is known to increase the risk of bleeding. We aimed to investigate the impact of OAC and ADPi therapies on short-term outcomes after traumatic brain injury (TBI). METHODS All adult patients hospitalized for TBI in Finland during 2005-2018 were retrospectively studied using a combination of national registries. Usage of pharmacy-purchased OACs and ADPis at the time of TBI was analyzed with the pill-counting method (Social Insurance Institution of Finland). The primary outcome was 30-day case-fatality (Finnish Cause of Death Registry). The secondary outcomes were acute neurosurgical operation (ANO) and admission duration (Finnish Care Register for Health Care). Baseline characteristics were adjusted with multivariable regression including age, sex, comorbidities, skull or facial fracture, OAC/ADPi treatment, initial admission location, and the year of TBI admission. RESULTS The study population included 57,056 persons (mean age 66 years) of whom 0.9% used direct oral anticoagulants (DOAC), 7.1% Vitamin K antagonists (VKA), and 2.3% ADPis. Patients with VKAs had higher case-fatality than patients without OAC (15.4% vs. 7.1%; adjHR 1.35, CI 1.23-1.48; p<0.0001). Case-fatality was lower with DOACs (8.4%) than with VKAs (adjHR 0.62, CI 0.44-0.87; p=0.005) and was not different from patients without OACs (adjHR 0.93, CI 0.69-1.26; p=0.634). VKA usage was associated with higher neurosurgical operation rate compared to non-OAC patients (9.1% vs. 8.3%; adjOR 1.33, CI 1.17-1.52; p<0.0001). There was no difference in operation rate between DOAC and VKA. ADPi was not associated with case-fatality or operation rate in the adjusted analyses. VKAs and DOACs were not associated with longer admission length compared with the non-OAC group, whereas the admissions were longer in the ADPi group compared with the non-ADPi group. CONCLUSION Preinjury use of VKA is associated with increases in short-term mortality and in need for ANOs after TBI. DOACs are associated with lower fatality than VKAs after TBI. ADPis were not independently associated with the outcomes studied. These results point to relative safety of DOACs or ADPis in patients at risk of head trauma and encourage to choose DOACs when oral anticoagulation is required. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among adults with TBI, mortality was significantly increased in those using VKAs but not in those using DOACs or ADPis.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Finland
| | - Jori O Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Finland
| | - Jussi O T Sipilä
- Clinical neurosciences, University of Turku, Turku, Finland; Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland.,Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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12
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Turcato G, Cipriano A, Park N, Zaboli A, Ricci G, Riccardi A, Barbieri G, Gianpaoli S, Guiddo G, Santini M, Pfeifer N, Bonora A, Paolillo C, Lerza R, Ghiadoni L. "Decision tree analysis for assessing the risk of post-traumatic haemorrhage after mild traumatic brain injury in patients on oral anticoagulant therapy". BMC Emerg Med 2022; 22:47. [PMID: 35331163 PMCID: PMC8944105 DOI: 10.1186/s12873-022-00610-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI. METHODS Three thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient's risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables. RESULTS ICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH. CONCLUSIONS The machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy.
| | - Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Naria Park
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy
| | - Giorgio Ricci
- Emergency Department, University of Verona, Verona, Italy.,Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
| | - Alessandro Riccardi
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Greta Barbieri
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Sara Gianpaoli
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Grazia Guiddo
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Massimo Santini
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy
| | - Antonio Bonora
- Emergency Department, University of Verona, Verona, Italy
| | - Ciro Paolillo
- Emergency Department, University of Verona, Verona, Italy.,Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
| | - Roberto Lerza
- Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy.,Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Lorenzo Ghiadoni
- Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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13
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Nederpelt C, Naar L, Meier K, van Wijck S, Krijnen P, Velmahos G, Kaafarani H, Rosenthal M, Schipper I. Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls. Eur J Trauma Emerg Surg 2022; 48:4297-4304. [PMID: 35267051 PMCID: PMC9532305 DOI: 10.1007/s00068-022-01938-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/20/2022] [Indexed: 11/24/2022]
Abstract
Introduction Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. Methods We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. Results A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15–0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36–7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15–2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06–1.87) compared to controls. Conclusion Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.
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Affiliation(s)
- Charlie Nederpelt
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands. .,Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States.
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Karien Meier
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Suzanne van Wijck
- Department of Trauma Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - George Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Haytham Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Martin Rosenthal
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, United States
| | - Inger Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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14
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Santing J, Lee YX, van der Naalt J, van den Brand C, Jellema K. Mild traumatic brain injury in elderly patients receiving direct oral anticoagulants: A systematic review and meta-analysis. J Neurotrauma 2022; 39:458-472. [DOI: 10.1089/neu.2021.0435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Juliette Santing
- Medisch Centrum Haaglanden Westeinde, 2901, Neurology, Lijnbaan 12, Den Haag, Netherlands, 2501 CK, ,
| | - Ying Xing Lee
- Medisch Centrum Haaglanden Westeinde, 2901, Neurology, Den Haag, Zuid-Holland, Netherlands
| | | | - Crispijn van den Brand
- Haaglanden Medical Center, Department of Emergency Medicine, Lijnbaan 32, The Hague, Zuid-Holland, Netherlands, 2512VA
| | - Korné Jellema
- Medisch Centrum Haaglanden, 2901, Den Haag, Zuid-Holland, Netherlands
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15
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Mild Head Trauma (MHT) and Antiplatelet Therapy. Reply to Lorenzati et al. Comment on "Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357". MEDICINA-LITHUANIA 2021; 57:medicina57090889. [PMID: 34577811 PMCID: PMC8469365 DOI: 10.3390/medicina57090889] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
We read your data with interest, and we truly appreciate the similar experience [...].
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16
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Valiuddin H, Calice M, Alam A, Millard J, Boehm K, Valiuddin Y, Laforest D, Ricardi R, Kaakaji R, Keyes D. Incidence of Traumatic Delayed Intracranial Hemorrhage Among Patients Using Direct Oral Anticoagulants. J Emerg Med 2021; 61:489-498. [PMID: 34175191 DOI: 10.1016/j.jemermed.2021.04.017] [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: 04/11/2020] [Revised: 04/16/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Emergency department visits due to head injury in the United States have increased significantly over the past decade, and parallel the increasing use of direct oral anticoagulants (DOACs). OBJECTIVE We investigated the incidence of delayed intracranial hemorrhage (DICH) in patients with head injury who were taking DOACs. METHODS We conducted a single-center retrospective study at a level II trauma center. All patients with head injury and using DOACs with an initial negative head computed tomography (HCT) scan from March 1, 2014 to December 31, 2017 were included. DICH was identified as a positive finding on repeat HCT performed within 24 h. Each case of DICH underwent blinded review by two additional neuroradiologists. Demographic data were collected; independent t-tests were used to compare group means and linear regression for variable correlations. RESULTS Two hundred and eighty-seven patients with mean age of 80 years (interquartile range 14 years) met inclusion criteria. Repeat HCT was performed in 224 study participants (78%). Five (1.7%) resulted in DICH, three of which might have been present on initial HCT, with an incidence rate ranging from 0.7% to 1.7%. Only two initial HCTs were read as negative by all three neuroradiologists; 60% disagreed on the initial read. Independent t-test procedures showed an association between DICH and higher Injury Severity Score (ISS). CONCLUSIONS We found a DICH incidence rate of 0.7-1.7%. ISS was statistically significant between the two groups. It is possible that in patients with a subjective estimation of low injury severity, a low mechanism of injury and reasonable outpatient follow-up, patients can be discharged home with standard head injury precautions and no repeat HCT, but further prospective studies are needed.
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Affiliation(s)
| | | | | | | | - Kevin Boehm
- Broward Health Medical Center, Fort Lauderdale, Florida
| | | | - Daniel Laforest
- Sparrow Hospital Michigan State University, Lansing, Michigan
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17
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Turcato G, Zaboli A, Zannoni M, Ricci G, Zorzi E, Ciccariello L, Tenci A, Pfeifer N, Maccagnani A, Bonora A. Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants. Am J Emerg Med 2021; 43:180-185. [DOI: 10.1016/j.ajem.2020.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/16/2020] [Accepted: 02/22/2020] [Indexed: 12/26/2022] Open
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18
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Puzio TJ, Murphy PB, Kregel HR, Ellis RC, Holder T, Wandling MW, Wade CE, Kao LS, McNutt MK, Harvin JA. Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis. J Am Coll Surg 2021; 232:1007-1016.e5. [PMID: 33766725 DOI: 10.1016/j.jamcollsurg.2021.02.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/26/2022]
Affiliation(s)
| | | | | | - Ryan C Ellis
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Travis Holder
- Houston Academy of Medicine-Texas Medical Center Library, Houston, TX
| | | | - Charles E Wade
- University of Texas Medical Center at Houston, Houston, TX
| | - Lillian S Kao
- University of Texas Medical Center at Houston, Houston, TX
| | | | - John A Harvin
- University of Texas Medical Center at Houston, Houston, TX
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19
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Marrone F, Zavatto L, Allevi M, Di Vitantonio H, Millimaggi DF, Dehcordi SR, Ricci A, Taddei G. Management of Mild Brain Trauma in the Elderly: Literature Review. Asian J Neurosurg 2021; 15:809-820. [PMID: 33708648 PMCID: PMC7869288 DOI: 10.4103/ajns.ajns_205_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/14/2020] [Accepted: 07/03/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose The world population is aging. As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions causing a challenge for the health-care system worldwide. The aim of this review is to delineate the specific and practice rules for the management of mild brain trauma in the elderly. Methods Systematic review of the last 15 years literature on mild traumatic brain injury (nTBI) in elderly patients. Results A total of 68 articles met all eligibility criteria and were selected for the systematic review. We collected 29% high-quality studies and 71% low-quality studies. Conclusion Clinical advices for a comprehensive management are provided. Current outcome data from mTBIs in the elderly show a condition that cannot be sustained in the future by families, society, and health-care systems. There is a strong need for more research on geriatric mild brain trauma addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies.
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Affiliation(s)
- Federica Marrone
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - Luca Zavatto
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - Mario Allevi
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy.,Department of Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, Italy
| | - Hambra Di Vitantonio
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | | | - Soheila Raysi Dehcordi
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Alessandro Ricci
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | - Graziano Taddei
- Department of Neurosurgery, San Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
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20
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Shin SS, Marsh EB, Ali H, Nyquist PA, Hanley DF, Ziai WC. Comparison of Traumatic Intracranial Hemorrhage Expansion and Outcomes Among Patients on Direct Oral Anticoagulants Versus Vitamin k Antagonists. Neurocrit Care 2021; 32:407-418. [PMID: 32034657 DOI: 10.1007/s12028-019-00898-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND With increasing use of direct oral anticoagulants (DOACs) and availability of new reversal agents, the risk of traumatic intracranial hemorrhage (tICH) requires better understanding. We compared hemorrhage expansion rates, mortality, and morbidity following tICH in patients treated with vitamin k antagonists (VKA: warfarin) and DOACs (apixaban, rivaroxaban, dabigatran). METHODS Retrospective chart review of patients from 2010 to 2017 was performed to identify patients with imaging diagnosis of acute traumatic intraparenchymal, subdural, subarachnoid, and epidural hemorrhage with preadmission use of DOACs or VKAs. We identified 39 patients on DOACs and 97 patients on VKAs. Demographic information, comorbidities, hemorrhage size, and expansion over time, as well as discharge disposition and Glasgow Outcome Scale (GOS) were collected. Primary outcome was development of new or enlargement of tICH within the first 48 h of initial CT imaging. RESULTS Of 136 patients with mean (SD) age 78.7 (13.2) years, most common tICH subtype was subdural hematoma (N = 102/136; 75%), and most common mechanism was a fall (N = 130/136; 95.6%). Majority of patients in the DOAC group did not receive reversal agents (66.7%). Hemorrhage expansion or new hemorrhage occurred in 11.1% in DOAC group vs. 14.6% in VKA group (p = 0.77) at a median of 8 and 11 h from initial ED admission, respectively (p = 0.82). Patients in the DOAC group compared to VKA group had higher median discharge GOS (4 vs. 3 respectively, p = 0.03), higher percentage of patients with good outcome (GOS 4-5, 66.7% vs. 40.2% respectively, p = 0.005), and higher rate of discharge to home or rehabilitation (p = 0.04). CONCLUSIONS We report anticoagulation-associated tICH outcomes predominantly due to fall-related subdural hematomas. Patients on DOACs had lower tICH expansion rates although not statistically significantly different from VKA-treated patients. DOAC-treated patients had favorable outcomes versus VKA group following tICH despite low use of reversal strategies. DOAC use may be a safer alternative to VKA in patients at risk of traumatic brain hemorrhage.
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Affiliation(s)
- Samuel S Shin
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hasan Ali
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Paul A Nyquist
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Neurocritical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Wendy C Ziai
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurocritical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Neurosciences Critical Care, The Johns Hopkins Hospital, 600 N. Wolfe St./Phipps 455, Baltimore, MD, 21287, USA.
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21
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Santing JAL, Van den Brand CL, Jellema K. Traumatic Brain Injury in Patients Receiving Direct Oral Anticoagulants. J Emerg Med 2020; 60:285-291. [PMID: 33067068 DOI: 10.1016/j.jemermed.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/19/2020] [Accepted: 09/03/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emergency departments (EDs) are faced with a growing number of patients with traumatic brain injury (TBI) using direct oral anticoagulants (DOACs). However, there remains uncertainty about the bleeding risk, rate of hematoma expansion, and the efficacy of reversal strategies in these patients. OBJECTIVE This study aims to identify the risk of traumatic hemorrhagic complications in patients with TBI using DOACs. METHODS In this retrospective study we included patients with TBI. All TBI patients were using DOACs, attended one of the three EDs of our hospital between January 2016 and October 2019, and received a computed tomography (CT) scan of the brain. The primary outcome was any traumatic intracranial hemorrhage on CT. Secondary outcomes were the use of reversal agents, secondary neurological deterioration, a neurosurgical intervention within 30 days after the injury, length of stay (LOS), Glasgow Outcome Scale (GOS) at discharge, and mortality. RESULTS Of the included patients (N = 316), 24 patients (7.6%, 95% confidence interval [CI] 4.2-9.8) presented with a traumatic intracranial hematoma (ICH). Seven patients (2.2%, 95% CI 0.6-3.8) received a reversal agent and 1 patient (0.3%, 95% CI -0.3-0.9) underwent a neurosurgical intervention. Of the 24 patients with a traumatic ICH, progression of the lesion was seen in 6 patients (1.9%, 95% CI 0.4-3.4). The mean LOS was 6.5 days (95% CI 3.0-10.1) and the mean GOS at discharge was 4 (95% CI 3.6-4.6). Death occurred in 1 patient (0.3%, 95% CI -0.3-0.9) suffering from an ICH. CONCLUSION Based on the present findings it can be postulated that TBI patients using DOACs have a low risk for ICH. Hematoma progression occurred, however, in a substantial number of patients. Considering the retrospective nature of the present study, future prospective trials are needed to confirm this finding.
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Affiliation(s)
| | - Crispijn L Van den Brand
- Department of Emergency Medicine, Haaglanden Medical Center, The Hague, the Netherlands; Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
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Fuller G, Sabir L, Evans R, Bradbury D, Kuczawski M, Mason SM. Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis. Emerg Med J 2020; 37:666-673. [PMID: 32900858 DOI: 10.1136/emermed-2019-209307] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/23/2020] [Accepted: 08/13/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group. METHODS An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies. RESULTS 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%). CONCLUSIONS The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.
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Affiliation(s)
- Gordon Fuller
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Lisa Sabir
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Rachel Evans
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- Emergency Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Maxine Kuczawski
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study. J Trauma Acute Care Surg 2020; 89:301-310. [DOI: 10.1097/ta.0000000000002760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Consequences of pre-injury utilization of direct oral anticoagulants in patients with traumatic brain injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020; 88:186-194. [PMID: 31688828 DOI: 10.1097/ta.0000000000002518] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The rapid adoption and widespread use of direct oral anticoagulants (DOACs) has outpaced research efforts to establish their effects in bleeding trauma patients. In patients with complicated traumatic brain injury (TBI) caused by intracranial hemorrhage, DOAC use may be associated with higher bleeding volume and potentially more disastrous sequelae than use of vitamin K antagonists (VKAs). In the current systematic review and meta-analysis we set out to evaluate the literature on the relationship between preinjury DOAC use and course of the intracranial hemorrhage. (ICH), its treatment and mortality rates in TBI patients, and to compare these outcomes to those of patients with preinjury VKA use. METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched using a search strategy including three main terms: "traumatic brain injury," "direct oral anticoagulants," and "vitamin K antagonists." There were 1,446 abstracts screened, and ultimately, six included articles. Random effects modeling meta-analysis was performed on in-hospital mortality, ICH progression and neurosurgical intervention rate. RESULTS All cohorts had similar baseline and emergency department parameters. Within individual studies surgery rate, reversal agents used, ICH progression and in-hospital mortality differed significantly between DOAC and VKA cohorts. Meta-analysis showed no significant difference in in-hospital mortality (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.23-4.06; I = 76%; p = 0.97), neurosurgical interventions (OR, 0.48; 95% CI, 0.14-1.63; p = 0.24), or ICH progression rates (OR, 1.86; 95% CI, 0.32-10.66; p = 0.49) between patients that used preinjury DOACs versus patients that used VKAs. CONCLUSION Direct oral anticoagulant-using mild TBI patients do not appear to be at an increased risk of in-hospital mortality, nor of increased ICH progression or surgery rates, compared with those taking VKAs. LEVEL OF EVIDENCE Systematic review, level III.
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Savioli G, Ceresa IF, Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, Marasco S, Manzoni F, Ciceri L, Gelfi E, Ricevuti G, Bressan MA. Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E308. [PMID: 32585829 PMCID: PMC7353902 DOI: 10.3390/medicina56060308] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 12/18/2022]
Abstract
Background and objectives: Anticoagulants are thought to increase the risks of traumatic intracranial injury and poor clinical outcomes after blunt head trauma. The safety of using direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) after intracranial hemorrhage (ICH) is unclear. This study aims to compare the incidence of post-traumatic ICH following mild head injury (MHI) and to assess the need for surgery, mortality rates, emergency department (ED) revisit rates, and the volume of ICH. Materials and Methods: This is a retrospective, single-center observational study on all patients admitted to our emergency department for mild head trauma from 1 January 2016, to 31 December 2018. We enrolled 234 anticoagulated patients, of which 156 were on VKAs and 78 on DOACs. Patients underwent computed tomography (CT) scans on arrival (T0) and after 24 h (T24). The control group consisted of patients not taking anticoagulants, had no clotting disorders, and who reported an MHI in the same period. About 54% in the control group had CTs performed. Results: The anticoagulated groups were comparable in baseline parameters. Patients on VKA developed ICH more frequently than patients on DOACs and the control group at 17%, 5.13%, and 7.5%, respectively. No significant difference between the two groups was noted in terms of surgery, intrahospital mortality rates, ED revisit rates, and the volume of ICH. Conclusions: Patients with mild head trauma on DOAC therapy had a similar prevalence of ICH to that of the control group. Meanwhile, patients on VKA therapy had about twice the ICH prevalence than that on the control group or patients on DOAC, which remained after correcting for age. No significant difference in the need for surgery was determined; however, this result must take into account the very small number of patients needing surgery.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Cristian Gragnaniello
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, IL 60656, USA;
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Mattia Del Maestro
- Department of Clinical-Surgical, PhD School in Experimental Medicine, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Marasco
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (S.L.); (A.G.L.); (S.M.)
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Luca Ciceri
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Elia Gelfi
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, -Saint Camillus International University of Health Sciences-Rome-Italy, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (L.C.); (E.G.); (M.A.B.)
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Are Direct Anticoagulants Safer in Traumatic Brain Injury Compared to Warfarin? Neurocrit Care 2020; 32:367-368. [PMID: 32096119 PMCID: PMC7082300 DOI: 10.1007/s12028-019-00912-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Valiuddin H, Alam A, Calice M, Boehm K, Millard J, Laforest D, Valiuddin Y, Ricardi R, Kaakaji R, Koch S, Oweis T, Keyes D. Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury. J Emerg Med 2020; 58:183-190. [DOI: 10.1016/j.jemermed.2020.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 12/31/2019] [Accepted: 01/09/2020] [Indexed: 01/24/2023]
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Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared with Vitamin K Antagonists. J Emerg Med 2019; 57:817-824. [PMID: 31648805 DOI: 10.1016/j.jemermed.2019.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The risk of intracranial hemorrhage (ICH) in patients taking direct oral anticoagulants (DOACs) after mild traumatic brain injury (MTBI) is unclear. OBJECTIVES To assess the differences in the risk of developing early, delayed, and comprehensive bleeding after MTBI among patients treated with DOACs as compared with those treated with vitamin K antagonists (VKAs). METHODS All MTBI patients taking oral anticoagulants in our emergency department between June 2017 and August 2018 were included. All patients on oral anticoagulants underwent immediate cerebral computed tomography (CT) and a second CT scan after 24 h of clinical observation. RESULTS There were 451 patients enrolled: 268 were on VKAs and 183 on DOACs. Of the DOAC-treated patients, 7.7% (14/183) presented overall intracranial bleeding, compared with 14.9% (40/268) of VKA-treated patients (p = 0.026). Early bleeding was present in 5.5% (10/183) of DOAC-treated patients and in 11.6% (31/268) of VKA-treated patients (p = 0.030). Multivariable analysis showed that VKA therapy (odds ratio [OR] 2.327), high-energy impact (OR 11.229), amnesia (OR 2.814), loss of consciousness (OR 5.286), Glasgow Coma Scale score < 15 (OR 4.719), and the presence of lesion above the clavicles (OR 2.742) were associated with significantly higher risk of global ICH. A nomogram was constructed to predict ICH using these six variables. Discrimination of the nomogram revealed good predictive abilities (area under the receiver operating characteristic curve: 0.817). CONCLUSIONS DOAC-treated patients seem to have lower risk of posttraumatic intracranial bleeding compared with VKA-treated patients.
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LaDuke ZJ, Hecht JP, Cain-Nielsen AH, Hemmila MR, Wahl WL. Association of mortality among trauma patients taking preinjury direct oral anticoagulants versus vitamin K antagonists. Surgery 2019; 166:564-571. [DOI: 10.1016/j.surg.2019.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/22/2019] [Accepted: 04/13/2019] [Indexed: 10/26/2022]
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30
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Spinola MB, Riccardi A, Minuto P, Campodonico P, Motta G, Malerba M, Guiddo G, Lerza R. Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants. Am J Emerg Med 2019; 37:1677-1680. [DOI: 10.1016/j.ajem.2018.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/29/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023] Open
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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: 42] [Impact Index Per Article: 8.4] [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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Should Adults With Mild Head Injury Who Are Receiving Direct Oral Anticoagulants Undergo Computed Tomography Scanning? A Systematic Review. Ann Emerg Med 2019; 73:66-75. [DOI: 10.1016/j.annemergmed.2018.07.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 12/18/2022]
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33
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The Basics of Antithrombotic Medications. TOPICS IN GERIATRIC REHABILITATION 2019. [DOI: 10.1097/tgr.0000000000000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cipriano A, Pecori A, Bionda AE, Bardini M, Frassi F, Leoli F, Lami V, Ghiadoni L, Santini M. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists. Intern Emerg Med 2018. [PMID: 29520701 DOI: 10.1007/s11739-018-1806-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Prognosis after mild traumatic brain injury (MTBI) on oral anticoagulant therapy (OAT) is uncertain. We evaluated the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) and the safety of a clinical management protocol. In this single-center prospective observational study, we enrolled 220 patients on OAT with MTBI. After a first negative CT scan, asymptomatic patients underwent a close neurological observation; if neurologically stable, they were discharged without a second CT scan and followed up for 1 month. Out of the 220 patients, 206 met the inclusion criteria. 23 of them (11.2%) had a positive first CT scan for ICH. Only 1 (0.5%, 95% CI 0.0-1.4%) died because of ICH; no one required neurosurgical intervention. The observed prevalence rate of immediate ICH resulted statistically higher in VKAs-treated patients compared to those treated with DOACs (15.7 vs. 4.7%, RR 3.34, 95% CI 1.18-9.46, P < 0.05). In the 1-month follow-up, 5 out of the 183 patients with a negative CT scan were lost. Out of the remaining 178 patients, only 3 showed a delayed ICH (1.7%, 95% CI 0.0-3.6%), 1 of them died (0.6%, 95% CI 0.5-1.7%) and the others did not require neurosurgical intervention. DOACs resulted safer than VKAs also in the setting of MTBI. In our observation, the rate of delayed hemorrhage was relatively low. Patients presenting with a negative first CT scan and without neurological deterioration could be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan.
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Affiliation(s)
- Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Alessio Pecori
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Alessandra Eugenia Bionda
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Michele Bardini
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Francesca Frassi
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Francesco Leoli
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Valentina Lami
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Lorenzo Ghiadoni
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Massimo Santini
- Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d'Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Batey M, Hecht J, Callahan C, Wahl W. Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly. Surgery 2018; 164:814-819. [PMID: 30098813 DOI: 10.1016/j.surg.2018.05.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 03/26/2018] [Accepted: 05/09/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Falls are now the leading cause of trauma and represent the most common type of trauma in the elderly. The use of anticoagulants is increasing in older patients, but there are little data on outcomes after traumatic brain injury while anticoagulated with direct oral anticoagulants compared with warfarin. We hypothesized that anticoagulated patients would have a greater mortality and complications than nonanticoagulated patients, and patients on direct oral anticoagulants would have more fatal outcomes after low-level falls because of lack of reversal agents. METHODS Patients 65 years or older admitted to level 1-3 trauma centers with 24-hour neurosurgical care were identified through the administrative database of 19 Trinity Health hospitals. Patients with International Classification of Diseases, Ninth Revision, codes consistent with low-level fall and traumatic brain injury from May 2013 through October 2015 were included. Preadmission warfarin or direct oral anticoagulant use was extracted from admission reconciliation of medications in the database. RESULTS A total of 700 patients met inclusion criteria with 177 on anticoagulants before admission. Anticoagulated patients had more cardiac (P < .001), pulmonary (P < .001), and clotting (P < .02) comorbidities. Warfarin patients had the greatest neurosurgical intervention rate at 18% compared with direct oral anticoagulants (2.8%, P < .02) or nonanticoagulation (11%, P < .02). No difference was identified in overall mortality and mortality after neurosurgical intervention between the nonanticoagulated, warfarin, or direct oral anticoagulant groups. Warfarin patients received more plasma (P < .001) and red cell transfusions (P = .035) with greater intensive care unit stays (P < .001) compared with direct oral anticoagulant or nonanticoagulated patients. With logistic regression, only advancing age (P < .05) and a lesser Glasgow Coma Scale score (P < .01) were associated with greater mortality. CONCLUSION Older direct oral anticoagulant patients with traumatic brain injury after low-level fall did not have increased morbidity or mortality compared with those treated with warfarin or who were not treated with anticoagulants. Concerns over the use of direct oral anticoagulant agents in this population may be overstated and deserve more scrutiny.
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Affiliation(s)
- Madelyn Batey
- University of Michigan Health System Department of Pharmacy, Ann Arbor, MI
| | - Jason Hecht
- Saint Joseph Mercy Ann Arbor, Department of Pharmacy, Ann Arbor, MI
| | - Cherise Callahan
- Saint Joseph Mercy Ann Arbor, Department of Pharmacy, Ann Arbor, MI
| | - Wendy Wahl
- Saint Joseph Mercy Ann Arbor, Department of Pharmacy, Ann Arbor, MI.
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Verschoof MA, Zuurbier CCM, de Beer F, Coutinho JM, Eggink EA, van Geel BM. Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study and meta-analysis. J Neurol 2017; 265:315-321. [PMID: 29236167 DOI: 10.1007/s00415-017-8701-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/02/2017] [Accepted: 12/05/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND/AIMS Patients with mild traumatic brain injury (mTBI) on anticoagulants have an increased risk of intracranial hemorrhage (ICH). However, consensus is lacking on whether to admit them after normal initial cranial CT. We evaluated the yield of 24-h neurological observation. METHODS Retrospective multicenter study including adult patients admitted over a 5-year period with mTBI on anticoagulation [therapeutic dose heparin, direct oral anticoagulant, or vitamin K antagonist (VKA) with international normalized ratio (INR) ≥ 1.7] and reportedly normal cranial CT obtained within 24 h after trauma. Primary endpoint was symptomatic ICH within 24 h of injury. Literature on delayed ICH in patients with mTBI and anticoagulation use was reviewed. RESULTS Of 17.643 mTBI patients, 905 met the inclusion criteria (median age 82 years). 97% used VKA (median INR 2.9). None developed delayed ICH within 24 h. Nine patients deteriorated neurologically due to ICH, four within 24 h (0.4%, 95% CI 0.1-1.2) and five on day 2, 18, 22, 36 and 52, respectively. In six patients, including all four that developed symptoms within 24 h, ICH was found upon reevaluation of initial imaging. The meta-analysis comprised of 9 studies with data from 2885 patients. The estimated pooled proportion of symptomatic delayed ICH or delayed diagnosis of ICH within 24 h was 0.2% (95% CI 0.0-0.5). CONCLUSIONS Delayed (diagnosis of) ICH within 24 h is very rare in mTBI patients on anticoagulants after reportedly normal initial CT. Routine hospitalization of these patients seems unwarranted when the initial cranial CT is scrupulously evaluated.
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Affiliation(s)
- Merelijne A Verschoof
- Department of Neurology, Haga Ziekenhuis, Els-Borst-Eilersplein 275, 2545 AA, The Hague, The Netherlands.
| | | | - Frank de Beer
- Department of Neurology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Evert A Eggink
- Department of Radiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Björn M van Geel
- Department of Neurology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
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37
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Jolobe OM. Glasgow coma scale versus computed tomography in prognostication. Am J Emerg Med 2017; 35:1190. [DOI: 10.1016/j.ajem.2017.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/21/2017] [Indexed: 11/27/2022] Open
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38
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Jolobe OMP. Choice of oral anticoagulants in older patients with non-valvular atrial fibrillation. Br J Hosp Med (Lond) 2017; 78:416. [DOI: 10.12968/hmed.2017.78.7.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Oscar MP Jolobe
- Retired Geriatrician Manchester Medical Society Manchester M13 9PL
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