Delayed intracranial hemorrhage in the anticoagulated patient

Miller, Joseph; Lieberman, Leedor; Nahab, Bashar; Hurst, Gina; Gardner-Gray, Jayna; Lewandowski, Aaron; Natsui, Shaw; Watras, Jill

doi:10.1097/ta.0000000000000725

Cited by 43 publications

(21 citation statements)

References 19 publications

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“…The mortality was similar for TBI between the medication groups. A recent systematic review and meta‐analysis have found, for warfarin, the risk of delayed intracranial hemorrhage (ICH) was low in minor head injury, and there was no increased risk of death for antiplatelet agents . These findings are consistent with our results.…”

Section: Discussionsupporting

confidence: 92%

Epidemiology and outcomes of missing admission medication history in severe trauma: A retrospective study

Miller

Morris

Fisicaro

et al. 2017

Emerg Medicine Australasia

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Objective Anticoagulant and antiplatelet (ACAP) drugs are associated with increased mortality in trauma patients, therefore medication history on admission is important. Whether these medications are recorded on trauma admission has not been investigated, nor if absence of a medication history is associated with worse patient outcomes. Methods We conducted a retrospective database review combining demographic and outcome data from the St George Hospital (Sydney) trauma registry with admission medication history in the electronic record. To contrast medications with a known increased risk (ACAP) to patients with unknown risk, patients were divided into three groups: those on ACAPs, no‐ACAP if medication history was present and no‐ACAP documented, or no‐Hx if no medication history recorded. Inclusion criteria were aged >16 and Injury Severity Score (ISS) >12. Admission demographic data and outcome data were compared between all three groups. Results Of 533 consecutive patients, 21% comprised the no‐Hx group, while 22% were on an ACAP and 57% not on an ACAP. No‐Hx patients had more severe head injuries and a younger median age compared to ACAP patients (42 vs 82 years old, P < 0.001). Mortality was higher for ACAP (24%; 95% CI 17–33%) compared to no‐ACAP (11%; 95% CI 8–16%) or no‐Hx patients (12%; 95% CI 7–20%) (P = 0.04). Conclusions While a large number of severe trauma patients were admitted without a medication history, no‐Hx patients did not appear at increased risk of adverse outcomes. ACAP patients had a higher mortality compared to no‐ACAP highlighting the vulnerability of this group.

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Section: Discussionsupporting

confidence: 92%

Epidemiology and outcomes of missing admission medication history in severe trauma: A retrospective study

Miller

Morris

Fisicaro

et al. 2017

Emerg Medicine Australasia

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“…This would be expected when anticoagulant therapy increases the hemorrhagic risk in itself, although head trauma can also promote trauma-induced coagulopathy and, consequently, ICH [ 35 , 57 , 58 , 59 , 60 , 61 ].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2020

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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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“…Low rates of DICH and even lower rates of subsequent neurosurgical operative intervention have caused many to question the value of the routine repeat head CT [ 19 ]. Yet, others still see it as a valuable tool to diagnose DICH, especially since there are no known predictors of DICH [ 18 , 24 ].…”

Section: Introductionmentioning

confidence: 99%

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

et al. 2018

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BackgroundFalls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy.MethodsData from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported.ResultsData on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications.ConclusionsUniversal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.

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Delayed intracranial hemorrhage in the anticoagulated patient

Abstract: Systematic review, level III.

Cited by 43 publications

References 19 publications

Epidemiology and outcomes of missing admission medication history in severe trauma: A retrospective study

Epidemiology and outcomes of missing admission medication history in severe trauma: A retrospective study

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

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

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