Role of antiplatelet therapy in the development of intracranial bleeding after mild traumatic brain injury

[Traumatic brain injury in patients over 65 years of age attended in the emergency department, characteristics and complications]

BACKGROUND AND OBJECTIVE

Ageing is associated with an increased risk of falls and trauma. The aim of the study was to assess the characteristics of patients over 65 years of age who consulted the ED for traumatic brain injury (TBI) in 2022, their relationship with cognitive impairment, functional dependence, use of oral antiplatelet/anticoagulant drugs and complications.

MATERIALS AND METHODS

Retrospective study conducted from 1 January to 31 December 2022. Demographic data were collected: age, sex, origin; cardiovascular risk factors; cognitive impairment using the Pfeiffer questionnaire; physical disability according to the Barthel Index; number of drugs; use of antiplatelet and oral anticoagulant (OAC); mechanism of fall; performance of cranial X-ray/CT, and presence of complications: intracranial haemorrhage (ICH), death.

RESULTS

599 patients were included. The mean age was 82.3±8.2 years. 63.8% were female and 36.2% male. 75.3% were from home, 24.7% from residence. No dementia in 61.4%, moderate-severe dementia in 38.6%. 58.1% were functionally independent, 25.1% had moderate-severe dependence. 85.7% had CVRF: HT 476 (79.5%), dyslipidaemia 354 (59.1%), DM 217 (36.2%), obesity 173 (28.9%), smoking 15 (2.5%). The number of drugs per patient was 9.2±4.3. Polypharmacy was present in 94.7% of patients. 35.9% were taking antiplatelet drugs and 30.2% anticoagulants. Intracranial haemorrhage occurred in 11 (2.3%) patients. Four (0.7%) patients died.

CONCLUSIONS

The TBI in our study was caused by low-energy trauma in a female patient, without dementia, functionally independent and with polypharmacy. There were few serious complications: 2.3% ICH and 0.7% deaths. 90.1% of ICH occurred in patients on antiplatelet and/or OAC therapy.

Does pre-injury clopidogrel use increase the risk of intracranial haemorrhage post head injury in adult patients? A systematic review and meta-analysis

BACKGROUND

Several current guidelines do not include antiplatelet use as an explicit indication for CT scan of the head following head injury. The impact of individual antiplatelet agent use on rates of intracranial haemorrhage is unclear. The primary objective of this systematic review was to assess if clopidogrel monotherapy was associated with traumatic intracranial haemorrhage (tICH) on CT of the head within 24 hours of presentation following head trauma compared with no antithrombotic controls.

METHODS

Eligible studies were non-randomised studies with participants aged ≥18 years old with head injury. Studies had to have conducted CT of the head within 24 hours of presentation and contain a no antithrombotic control group and a clopidogrel monotherapy group.Eight databases were searched from inception to December 2020. Assessment of identified studies against inclusion criteria and data extraction were carried out independently and in duplicate by two authors.Quality assessment and risk of bias (ROB) were assessed using the Newcastle-Ottawa Quality Assessment tool and Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was conducted using a random-effects model and reported as an OR and 95% CI.

RESULTS

Seven studies were eligible for inclusion with a total of 21 898 participants that were incorporated into the meta-analysis. Five studies were retrospective. Clopidogrel monotherapy was not significantly associated with an increase in risk of tICH compared with no antithrombotic controls (OR 0.97, 95% CI 0.54 to 1.75). Heterogeneity was high with an I² of 75%. Sensitivity analysis produced an I² of 21% and did not show a significant association between clopidogrel monotherapy and risk of tICH (OR 1.16, 95% CI 0.87 to 1.55). All studies scored for moderate to serious ROB on categories in the ROBINS-I tool.

CONCLUSION

Included studies were vulnerable to confounding and several were small-scale studies. The results should be interpreted with caution given the ROB identified. This study does not provide statistically significant evidence that clopidogrel monotherapy patients are at increased risk of tICH after head injury compared with no antithrombotic controls.

PROSPERO REGISTRATION NUMBER

CRD42020223541.