Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum

Abstract

Background: Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk. Methods: Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression. Results: Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes. Conclusions: Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.

Time Course of Hemostatic Disruptions After Traumatic Brain Injury: A Systematic Review of the Literature

“…There is controversy regarding the exact nature of hemostatic disruption after TBI, and evidence exists to support the presence of both a hyper-and hypocoagulable state [2]. While the initial head injury often leads to impaired clot formation and exacerbation of hemorrhagic lesions [2,[7][8][9], TBI is also independently associated with an increased risk of venous thromboembolism [10][11][12][13] and ischemic stroke [14][15][16][17][18]. Most likely, there is a progression from early increased bleeding risk to a later prothrombotic state.…”

Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single‐center Experience in the Post–CRASH‐2 Era

“…30 In recent studies, it was demonstrated that in hospitalized older patients with traumatic brain injury (TBI) and in patients with greater TBI severity, incidence of acute thromboembolic events was significantly higher. 31,32 It is possible that patients with TBI and intracranial hemorrhage may have prophylaxis withheld, thereby exposing these patients to an increased risk for thromboembolic disease. However, it is noted in our study that 120 patients sustained a head injury and only seven (5.8%) had a thromboembolic event which is a similar rate to the overall thromboembolic event rate of 6.6%.…”

Administration of Yunnan Baiyao improved clinical prognosis of emergency craniotomy in patients with moderate-to-severe TBI: a randomized controlled trial

“…Intracranial bleeding, edema and coagulopathy are major predictors of mortality and morbidity of TBI that still lacks of effective therapy [9,53,54]. YB and its major active ingredient Notoginseng saponins (PNS) have dual anti-hemorrhage and anti-hemostasis properties [19,55].…”

“…Surgical removal of intracranial hematoma and fractured brain tissue (craniotomy/decompression craniectomy) can reduce the mortality of severe TBI, incidence of ICP, and length of hospital stay in TBI patients [2][3][4]. Surgery, however, could also worsen the clinical outcomes of TBI [5,6], partly due to secondary injury, increased gastrointestinal bleeding and in ammatory complications [4,[7][8][9][10][11].…”