Delayed intracranial hemorrhage in the patient with blunt trauma on anticoagulant or antiplatelet agents: routine repeat head computed tomography is unnecessary

Hill, Josh; Bonner, Paul; OʼMara, Michael Shay; Wood, Teresa L.; Lieber, Michael L.

doi:10.1080/02699052.2018.1441442

Cited by 18 publications

(14 citation statements)

References 14 publications

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“…The results of our study, with only one clinically significant case of delayed intracranial hemorrhage (0.3% in the repeat CT group, 0.1% in total), support other investigations which concluded that a routine repeat CT is not necessary for patients with antithrombotic therapy, due to the low clinical significance of most detected DIH [27,28,29,30,31,32]. The single case of a clinically significant DIH in our study showed an altered neurological status and would therefore have received an additional CT during the observation period regardless of clinical protocol for routine repeat CT.…”

Section: Discussionsupporting

confidence: 88%

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

Antoni

Schwendenwein

Binder

et al. 2019

JCM

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Background: Delayed intracranial hemorrhage can occur up to several weeks after head trauma and was reported more frequently in patients with antithrombotic therapy. Due to the risk of delayed intracranial hemorrhage, some hospitals follow extensive observation and cranial computed tomography (CT) protocols for patients with head trauma, while others discharge asymptomatic patients after negative CT. Methods: We retrospectively analyzed data on patients with head trauma and antithrombotic therapy without pathologies on their initial CT. During the observation period, we followed a protocol of routine repeat CT before discharge for patients using vitamin K antagonists, clopidogrel or direct oral anticoagulants. Results: 793 patients fulfilled the inclusion criteria. Acetylsalicylic acid (ASA) was the most common antithrombotic therapy (46.4%), followed by vitamin K antagonists (VKA) (32.2%) and Clopidogrel (10.8%). We observed 11 delayed hemorrhages (1.2%) in total. The group of 390 patients receiving routine repeat CT showed nine delayed hemorrhages (2.3%). VKA were used in 6 of these 11 patients. One patient needed an urgent decompressive craniectomy while the other patients were discharged after an extended observation period. The patient requiring surgical intervention due to delayed hemorrhage showed neurological deterioration during the observation period. Conclusions: Routine repeat CT scans without neurological deterioration are not necessary if patients are observed in a clinical setting. Patients using ASA as single antithrombotic therapy do not require in-hospital observation after a negative CT scan.

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Section: Discussionsupporting

confidence: 88%

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

Antoni

Schwendenwein

Binder

et al. 2019

JCM

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“…Like other published studies, our findings showed the incidence of ICH-d to be low, within the reported range of 0.3% to 6% (5,8,10,11,(13)(14)(15)(16)(17). However, nearly all prior studies focus on patients taking warfarin with or without an antiplatelet agent.…”

Section: A C C E P T E Dsupporting

confidence: 84%

“…In anticoagulated patients, there is concern for delayed intracranial hemorrhage (ICH-d), which occurs when acute hemorrhage is not present on the initial CTH, but develops later. For patients on anticoagulants, there are no national guidelines for repeat imaging after an initial negative CTH, leading to a variety of practices including routine repeat CTH, serial neurologic exams in the emergency department, admission for 24-hour observation, and discharge home (8)(9)(10)(11)(12).…”

Section: Introductionmentioning

confidence: 99%

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Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study

Cohan¹,

Beattie²,

Bowman³

et al. 2020

J Trauma Acute Care Surg

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Background:The number of trauma patients on prehospital novel oral anticoagulants (NOACs) is increasing. After an initial negative computed tomography of the head (CTH), practice patterns are variable for obtaining repeat CTH to evaluate for delayed intracranial hemorrhage (ICH-d). However, the risks and outcomes of ICH-d for patients on NOACs are unclear. We hypothesized that for these patients, the incidence of ICH-d is low, similar to that of warfarin, and when it occurs, does not result in clinically significant worse outcomes. Methods: Five Level-1 trauma centers in Northern California participated in a retrospective review of anticoagulated trauma patients. Patients were included if their initial CTH was negative. Primary outcomes were incidence of ICH-d, neurosurgical intervention, and death. Patient factors associated with the outcome of ICH-d were determined by multivariable regression. Results: From 2016 to 2018, 777 patients met inclusion criteria (NOAC: n=346; warfarin: n=431), 54% of whom received a repeat CTH. ICH-d incidence was 2.3% in the NOAC group and 4% in the warfarin group (p=0.31). No NOAC patient with ICH-d required neurosurgical intervention or died because of their head injury. Two warfarin patients received neurosurgical intervention and three died from their head injury. Head Abbreviated Injury Scale ≥ 3 was associated with increased odds of developing ICH-d (aOR 32.70, p<0.01). Conclusion:The incidence of ICH-d in patients taking NOAC is low. In this study, patients on NOACs who developed ICH-d after an initial negative CTH did not need neurosurgical

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“…The studies were published between 2009 and 2019; one study was performed in Italy [ 17 ], eleven studies in the USA [ 11 , 18 – 27 ], three studies in Austria [ 28 – 30 ] and one in Australia [ 31 ]. Four studies were multicentric [ 20 , 24 , 27 , 31 ], twelve had a retrospective design [ 11 , 17 – 19 , 22 , 23 , 25 – 28 , 30 , 31 ] and four had a prospective design [ 20 , 21 , 24 , 29 ]. Two studies were described in abstracts only [ 18 , 31 ], and the remaining 14 studies were published as full-text articles.…”

Section: Resultsmentioning

confidence: 99%

Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis

Colombo

Bonzi

Fiorelli

et al. 2021

Scand J Trauma Resusc Emerg Med

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Background The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients. Objective The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA. Methods A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death). Results Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23–1.52%), ranging from 0 to 4%, with substantial heterogeneity (I2 = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04). Conclusion Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge.

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Delayed intracranial hemorrhage in the patient with blunt trauma on anticoagulant or antiplatelet agents: routine repeat head computed tomography is unnecessary

Cited by 18 publications

References 14 publications

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study

Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis

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