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Vellek J, Tarawneh OH, Kazim SF, Owodunni OP, Arbuiso S, Shah S, Dicpinigaitis AJ, Schmidt MH, McKee RG, Miskimins R, Al-Mufti F, Bowers CA. Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study. World Neurosurg X 2024; 23:100367. [PMID: 38590738 PMCID: PMC10999854 DOI: 10.1016/j.wnsx.2024.100367] [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: 12/08/2022] [Revised: 03/06/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.
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Affiliation(s)
- John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Omar H. Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Oluwafemi P. Owodunni
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Sophia Arbuiso
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Smit Shah
- PRISMA Health Richland/University of South Carolina School of Medicine, 1 Medical Park, Suite 230, Columbia, SC, 29203, United States
| | | | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Rohini G. McKee
- Department of Surgery, University of New Mexico, Albuquerque, NM, 87106, United States
| | - Richard Miskimins
- Department of Surgery, University of New Mexico, Albuquerque, NM, 87106, United States
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, United States
| | - Christian A. Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, United States
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Ghafil C, Park C, Yu J, Drake A, Sundaram S, Thiele L, Graham C, Inaba K, Matsushima K. The risk of hemorrhagic complications after anticoagulation therapy in trauma patients: A multicenter evaluation. J Trauma Acute Care Surg 2024; 96:757-762. [PMID: 37962213 PMCID: PMC11043002 DOI: 10.1097/ta.0000000000004209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND The use of anticoagulation therapy (ACT) in trauma patients during the postinjury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions. METHODS In this retrospective cohort study, all trauma admissions at two Level I trauma centers between January 2015 and December 2020 were reviewed. Patients with preexisting ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury. RESULTS A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the postinjury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7 days to 14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively. CONCLUSION The use of ACT in trauma during the postinjury period is not without risk. Waiting 7 days to 14 days postinjury might greatly reduce the risk of hemorrhagic complications. LEVEL OF EVIDENCE Therapeutic/Care Management Study; Level IV.
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Affiliation(s)
- Cameron Ghafil
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Caroline Park
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Jeremy Yu
- Department of Preventive Medicine, University of Southern California, 1845 N Soto St. Los Angeles, CA, USA 90032
| | - Andrew Drake
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Shivani Sundaram
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Lisa Thiele
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Caleb Graham
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Kenji Inaba
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
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McGrath M, Sarhadi K, Harris MH, Baird-Daniel E, Greil M, Barrios-Anderson A, Robinson E, Fong CT, Walters AM, Lele AV, Wahlster S, Bonow R. Utility of Routine Surveillance Head Computed Tomography After Receiving Therapeutic Anticoagulation in Patients with Acute Traumatic Intracranial Hemorrhage. World Neurosurg 2024; 185:e1114-e1120. [PMID: 38490443 DOI: 10.1016/j.wneu.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024]
Abstract
INTRODUCTION Patients with traumatic intracranial hemorrhage (tICH) are at increased risk of venous thromboembolism and may require anticoagulation. We evaluated the utility of surveillance computed tomography (CT) in patients with tICH who required therapeutic anticoagulation. METHODS This single institution, retrospective study included adult patients with tICH who required anticoagulation within 4 weeks and had a surveillance head CT within 24 hours of reaching therapeutic anticoagulation levels. The primary outcome was hematoma expansion (HE) detected by the surveillance CT. Secondary outcomes included 1) changes in management in patients with HE on the surveillance head CT, 2) HE in the absence of clinical changes, and 3) mortality due to HE. We also compared mortality between patients who did and did not have a surveillance CT. RESULTS Of 175 patients, 5 (2.9%) were found to have HE. Most (n = 4, 80%) had changes in management including anticoagulation discontinuation (n = 4), reversal (n = 1), and operative management (n = 1). Two patients developed symptoms or exam changes prior to the head CT. Of the 3 patients (1.7%) without preceding exam changes, each had only very minor HE and did not require operative management. No patient experienced mortality directly attributed to HE. There was no difference in mortality between patients who did and those who did not have a surveillance scan. CONCLUSIONS Our findings suggest that most patients with tICH who are started on anticoagulation could be followed clinically, and providers may reserve CT imaging for patients with changes in exam/symptoms or those who have a poor clinical examination to follow.
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Affiliation(s)
- Margaret McGrath
- Department of Neurological Surgery, University of Washington, Seattle, Washington.
| | - Kasra Sarhadi
- Department of Neurology, University of Washington, Seattle, Washington
| | - Mark H Harris
- School of Medicine, University of California, Irvine, California
| | - Eliza Baird-Daniel
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Madeline Greil
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Ellen Robinson
- Quality Improvement, Harborview Medical Center, Seattle, Washington
| | - Christine T Fong
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Andrew M Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Abhijit V Lele
- Department of Neurological Surgery, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington; Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington
| | - Sarah Wahlster
- Department of Neurological Surgery, University of Washington, Seattle, Washington; Department of Neurology, University of Washington, Seattle, Washington; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington; Harborview Injury Prevention Research Center, University of Washington, Seattle, Washington
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Nagai A, Karibe H, Narisawa A, Kameyama M, Ishikawa S, Iwabuchi N, Tominaga T. Cerebral infarction following administration of andexanet alfa for anticoagulant reversal in a patient with traumatic acute subdural hematoma. Surg Neurol Int 2023; 14:286. [PMID: 37680936 PMCID: PMC10481803 DOI: 10.25259/sni_358_2023] [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: 04/23/2023] [Accepted: 07/25/2023] [Indexed: 09/09/2023] Open
Abstract
Background Anticoagulants prevent thrombosis in patients with atrial fibrillation (AF) and venous thromboembolism but increase the risk of hemorrhagic complications. If severe bleeding occurs with anticoagulant use, discontinuation and rapid reversal are essential. However, the optimal timing for resuming anticoagulants after using reversal agents remains unclear. Here, we report early cerebral infarction following the use of andexanet alfa (AA), a specific reversal agent for factor Xa inhibitors, in a patient with traumatic acute subdural hematoma (ASDH). The possible causes of thromboembolic complication and the optimal timing for anticoagulant resumption are discussed. Case Description An 84-year-old woman receiving rivaroxaban for AF presented with impaired consciousness after a head injury. Computed tomography (CT) revealed right ASDH. The patient was administered AA and underwent craniotomy. Although the hematoma was entirely removed, she developed multiple cerebral infarctions 10 h after the surgery. These infarctions were considered cardiogenic cerebral embolisms and rivaroxaban was therefore resumed on the same day. This case indicates the possibility of early cerebral infarction after using a specific reversal agent for factor Xa inhibitors. Conclusion Most studies suggest that the safest time for resuming anticoagulants after using reversal agents is between 7 and 12 days. The present case showed that embolic complications may develop much earlier than expected. Early readministration of anticoagulant may allow for adequate prevention of the acute thrombotic syndromes.
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Affiliation(s)
- Arata Nagai
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Hiroshi Karibe
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Ayumi Narisawa
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Motonobu Kameyama
- Department of Neurosurgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Shuichi Ishikawa
- Department of Neurosurgery, Isinomaki Red Cross Hospital, Ishinomaki, Japan
| | - Naoya Iwabuchi
- Department of Neurosurgery, Isinomaki Red Cross Hospital, Ishinomaki, Japan
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
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Siletz AE, Dhillon NK, Fierro NM, Muñiz T, Loran P, Singer M, Hashim YM, Ley EJ. Complications and Transfusions on Therapeutic Anticoagulation After Trauma. Am Surg 2022; 88:2451-2455. [PMID: 35549566 DOI: 10.1177/00031348221101492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Trauma patients who develop indications for therapeutic anticoagulation (TAC) present a challenge due to concern for bleeding. Transfusion requirement has been described as a common complication of TAC after trauma but its clinical relevance is unclear. OBJECTIVE Determine risk factors for and clinical outcomes associated with transfusion requirement on TAC after trauma. METHODS All trauma patients admitted to an academic urban level I trauma center from January 2010 to August 2020 who received TAC were included in this retrospective cohort study. Data included injury characteristics; TAC indication and timing; transfusions; and interventions. Patients who required transfusion after TAC were compared to those who did not. RESULTS Eighty-two patients were included. The most common reasons for TAC were deep vein thrombosis (67.1%) and pulmonary embolism (31.7%). Two (2.4%) patients developed gastrointestinal bleeding. One (1.2%) underwent endoscopic intervention. Two patients (4.9%) had intracranial hemorrhage progression. Blood transfusion after TAC initiation was required in 43.9% of patients. Patients who were transfused started TAC more quickly after traumatic injury (5.5 vs 10.0 days, P = .03), had fewer hospital-free days (54 vs 64 days, P < .01), ICU-free days (8.5 vs 16.5 days, P = .01), and higher mortality (13.9% vs 2.1%, P = .04). CONCLUSION Transfusions are common after starting TAC in trauma patients. Requiring transfusion after starting TAC was associated with shorter time from injury to starting TAC, higher mortality, and fewer ICU and hospital-free days.
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Affiliation(s)
| | | | | | - Tobias Muñiz
- 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Priya Loran
- 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | - Eric J Ley
- 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Nguyen T, Sharma M, Crooks P, Patel PV, Bonow RH, Creutzfeldt CJ, Wahlster S. Between scylla and charybdis: risks of early therapeutic anticoagulation for venous thromboembolism after acute intracranial hemorrhage. Br J Neurosurg 2022; 36:251-257. [PMID: 35343356 DOI: 10.1080/02688697.2022.2054944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To assess the risk of hematoma expansion in patients with acute intracranial hemorrhage (ICH) requiring therapeutic anticoagulation for the treatment of venous thromboembolism. METHODS We retrospectively reviewed all patients at our institution between 2014 and 2019 who were therapeutically anticoagulated for venous thromboembolism within 4 weeks after ICH. We included subtypes of traumatic ICH and spontaneous intraparenchymal hemorrhage. Our main outcome was the incidence of hematoma expansion within 14 days from initiating therapeutic anticoagulation. Hematoma expansion was defined as (1) radiographically proven expansion leading to cessation of therapeutic anticoagulation or (2) death due to hematoma expansion. Secondary outcomes included mortality due to hematoma expansion and characteristics associated with hematoma expansion. RESULTS Fifty patients met inclusion criteria (mean age: 54 years, 80% male, 76% Caucasian); 24% had undergone a neurosurgical procedure prior to therapeutic anticoagulation. Median time from ICH to therapeutic anticoagulation initiation was 9.5 days (IQR 4-17), 40% received therapeutic anticoagulation in <7 days after ICH. Six patients (12%) developed hematoma expansion, of whom two (4%) died. While not statistically significant, patients with hematoma expansion tended to be older (57.8 vs. 53.5 years), were anticoagulated sooner (4 vs. 10 days), presented with lower GCS (50% vs. 39% with GCS <8), higher hematoma volume (50% vs. 42% >30 cc), and higher SDH diameter (16 mm vs. 8.35 mm). There was a trend towards greater risk of hematoma expansion for patients undergoing endoscopic ICH evacuation (16% vs. 2%, p = 0.09); patients with hematoma expansion were more likely to present with hydrocephalus (67% vs. 16%, p = 0.02). CONCLUSIONS Our study is among the first to explore characteristics associated with hematoma expansion in patients undergoing therapeutic anticoagulation after acute ICH. Larger studies in different ICH subtypes are needed to identify determinants of hematoma expansion in this high-acuity population.
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Affiliation(s)
- Thuhien Nguyen
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Patrick Crooks
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - Pratik V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Robert H Bonow
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | | | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, WA, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.,Department of Neurosurgery, University of Washington, Seattle, WA, USA
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Milling TJ, Warach S, Johnston SC, Gajewski B, Costantini T, Price M, Wick J, Roward S, Mudaranthakam D, Dula AN, King B, Muddiman A, Lip GY. Restart TICrH: An Adaptive Randomized Trial of Time Intervals to Restart Direct Oral Anticoagulants after Traumatic Intracranial Hemorrhage. J Neurotrauma 2021; 38:1791-1798. [PMID: 33470152 PMCID: PMC8219199 DOI: 10.1089/neu.2020.7535] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Anticoagulants prevent thrombosis and death in patients with atrial fibrillation and venous thromboembolism (VTE) but also increase bleeding risk. The benefit/risk ratio favors anticoagulation in most of these patients. However, some will have a bleeding complication, such as the common trip-and-fall brain injury in elderly patients that results in traumatic intracranial hemorrhage. Clinicians must then make the difficult decision about when to restart the anticoagulant. Restarting too early risks making the bleeding worse. Restarting too late risks thrombotic events such as ischemic stroke and VTE, the indications for anticoagulation in the first place. There are more data on restarting patients with spontaneous intracranial hemorrhage, which is very different than traumatic intracranial hemorrhage. Spontaneous intracranial hemorrhage increases the risk of rebleeding because intrinsic vascular changes are widespread and irreversible. In contrast, traumatic cases are caused by a blow to the head, usually an isolated event portending less future risk. Clinicians generally agree that anticoagulation should be restarted but disagree about when. This uncertainty leads to long restart delays causing a large, potentially preventable burden of strokes and VTE, which has been unaddressed because of the absence of high quality evidence. Restart Traumatic Intracranial Hemorrhage (the "r" distinguished intracranial from intracerebral) (TICrH) is a prospective randomized open label blinded end-point response-adaptive clinical trial that will evaluate the impact of delays to restarting direct oral anticoagulation (1, 2, or 4 weeks) on the composite of thrombotic events and bleeding in patients presenting after traumatic intracranial hemorrhage.
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Affiliation(s)
| | - Steven Warach
- Seton Dell Medical School Stroke Institute, Austin, Texas, USA
| | | | - Byron Gajewski
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Todd Costantini
- Department of Surgery, University of California – San Diego, La Jolla, California, USA
| | - Michelle Price
- Coalition for National Trauma Research, San Antonio, Texas, USA
| | - Jo Wick
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Simin Roward
- Department of Surgery, Dell Seton Medical Center at The University of Texas, Austin, Texas, USA
| | - Dinesh Mudaranthakam
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Ben King
- Department of Health Systems and Population Health, University of Houston, College of Medicine, Houston, Texas, USA
| | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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King B, Milling T, Gajewski B, Costantini TW, Wick J, Price MA, Mudaranthakam D, Stein DM, Connolly S, Valadka A, Warach S. Restarting and timing of oral anticoagulation after traumatic intracranial hemorrhage: a review and summary of ongoing and planned prospective randomized clinical trials. Trauma Surg Acute Care Open 2020; 5:e000605. [PMID: 33313417 PMCID: PMC7716676 DOI: 10.1136/tsaco-2020-000605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/27/2022] Open
Abstract
Anticoagulant-associated traumatic intracranial hemorrhage (tICrH) is a devastating injury with high morbidity and mortality. For survivors, treating clinicians face the dilemma of restarting oral anticoagulation with scarce evidence to guide them. Thromboembolic risk is high from the bleeding event, patients’ high baseline risks, that is, the pre-existing indication for anticoagulation, and the risk of immobility after the bleeding episode. This must be balanced with potentially devastating hematoma expansion or new hemorrhagic lesions. Retrospective evidence and expert opinion support restarting oral anticoagulants in most patients with tICrH, but timing is uncertain. Researchers have failed to make clear distinctions between tICrH and spontaneous intracranial hemorrhage (sICrH), which have differing natural histories. While both appear to benefit from restarting, sICrH has a higher rebleeding risk and similar or lower thrombotic risk. Clinical equipoise on restarting is also divergent. In sICrH, equipoise is centered on whether to restart. In tICrH, it is centered on when. Several prospective randomized clinical trials are ongoing or about to start to examine the risk–benefit of restarting. Most of them are restricted to patients with sICrH, with antiplatelet control groups. Most are also restricted to direct oral anticoagulants (DOACs), as they are associated with a lower overall risk of ICrH. There is some overlap with tICrH via subdural hematoma, and one trial is specific to restart timing with DOACs in only traumatic cases. This is a narrative review of the current evidence for restarting anticoagulation and restart timing after tICrH along with a summary of the ongoing and planned clinical trials.
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Affiliation(s)
- Ben King
- College of Medicine, Department of Health Systems and Population Health Sciences, University of Houston, Houston, Texas, USA
| | - Truman Milling
- Seton Dell Medical School Stroke Institute, Ascension Seton, Austin, Texas, USA
| | - Byron Gajewski
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, California, USA
| | - Jo Wick
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Dinesh Mudaranthakam
- Department of Biostatistics and Data Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Deborah M Stein
- Department of Surgery, University of California-San Francisco, School of Medicine, San Francisco, California, USA
| | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alex Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Steven Warach
- Department of Neurology, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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Therapeutic anticoagulation in patients with traumatic brain injuries and pulmonary emboli. J Trauma Acute Care Surg 2020; 89:529-535. [PMID: 32467467 DOI: 10.1097/ta.0000000000002805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with traumatic intracranial hemorrhage (ICH) and concomitant pulmonary embolus (PE) have competing care needs and demand a careful balance of anticoagulation (AC) versus potential worsening of their ICH. The goal of this study is to determine the safety of therapeutic AC for PE in patients with ICH. METHODS This is a retrospective single-center study of patients older than 16 years with concomitant ICH and PE occurring between June 2013 and December 2017. Early AC was defined as within 7 days of injury or less; late was defined as after 7 days. Primary outcomes included death, interventions for worsening ICH following AC, and pulmonary complications. Multivariate logistic regression was used to evaluate for clinical and demographic factors associated with worsening traumatic brain injury (TBI), and recursive partitioning was used to differentiate risk in groups. RESULTS Fifty patients met criteria. Four did not receive any AC and were excluded. Nineteen (41.3%) received AC early (median, 4.1; interquartile range, 3.1-6) and 27 (58.7%) received AC late (median, 14; interquartile range, 9.7-19.5). There were four deaths in the early group, and none in the late cohort (21.1% vs. 0%, p = 0.01). Two deaths were due to PE and the others were from multi-system organ failure or unrecoverable underlying TBI. Three patients in the early group, and two in the late, had increased ICH on computed tomography (17.6% vs. 7.4%, p = 0.3). None required intervention. CONCLUSION This retrospective study failed to find instances of clinically significant progression of TBI in 46 patients with computed tomography-proven ICH after undergoing AC for PE. Therapeutic AC is not associated with worse outcomes in patients with TBI, even if initiated early. However, two patients died from PE despite AC, underlining the severity of the disease. Intracranial hemorrhage should not preclude AC treatment for PE, even early after injury. LEVEL OF EVIDENCE Care management, Level IV.
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