Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared with Vitamin K Antagonists

Turcato, Gianni; Zannoni, M; Zaboli, Arian; Zorzi, Elisabetta; Ricci, Giorgio; Pfeifer, Norbert; Antonio, Miguel; Tenci, Andrea; Bonora, Antonio

doi:10.1016/j.jemermed.2019.09.007

Cited by 40 publications

(37 citation statements)

References 23 publications

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“…A higher rate of delayed ICH in patients anticoagulated with warfarin compared with DOACs was also seen in several smaller retrospective and prospective observational studies. 1,14,[21][22][23][24] Our systematic review of 3,051 patients on DOAC or warfarin found the pooled, weighted rate of delayed ICH to be similarly low in patients on DOACs compared with those on warfarin (2.43% vs 2.31%). There was low clinical and statistical heterogeneity between studies.…”

Section: Discussionmentioning

confidence: 97%

“…The higher rate of delayed ICH in patients on warfarin may have been due to a larger percentage of patients with elevated INR. Unlike warfarin, DOAC medications have no easily discernable measure 22 Barmparas et al 2018 17 Battle et al 2011 13 Bauman et al 2017 1 Chenoweth et al 2018 9 Cipriano et al 2018 19 Cocca et al 2019 18 Cohan et al 2020 21 Mann et al 2018 20 Marques et al 2019 23 Riccardi et al 2017 14 Turcato et al 2019 24 Type of study 22 Barmparas et al 2018 17 Battle et al 2011 13 Bauman et al 2017 1 Chenoweth et al 2018 9 Cipriano et al 2018 19 Cocca et al 2019 18 Cohan et al 2020 21 Mann et al 2018 20 Marques et al 2019 23 Riccardi et al 2017 14 Turcato et al 2019 24 Outcomes/ conclusions Delayed ICH, n (%) of anticoagulation degree, so risk factors for developing delayed ICH in these patients are even more elusive.…”

Section: Discussionmentioning

confidence: 99%

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Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis

Puzio

Murphy

Kregel

et al. 2021

Journal of the American College of Surgeons

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis

Puzio

Murphy

Kregel

et al. 2021

Journal of the American College of Surgeons

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“…14 The findings of this study are consistent with a multicenter prospective observational study that recently demonstrated similar ICH progression rates among anticoagulant agents and with multiple studies that suggest that DOAC have lower rates of ICH after injury. [15][16][17][18] Both Salami et al, who evaluated patients presenting to the emergency department who underwent head CT on either DOACs or warfarin, and Turcato et al, who evaluated 451 anticoagulated patients after head injury, found patients on warfarin were over twice as likely to develop ICH after head trauma. 16,17 A query of the American College of Surgeons Trauma Quality Improvement Program has also suggested that patients presenting on DOACs are less likely to undergo neurosurgical procedures and have lower mortality rates than those on warfarin.…”

Section: Discussionmentioning

confidence: 99%

“…[15][16][17][18] Both Salami et al, who evaluated patients presenting to the emergency department who underwent head CT on either DOACs or warfarin, and Turcato et al, who evaluated 451 anticoagulated patients after head injury, found patients on warfarin were over twice as likely to develop ICH after head trauma. 16,17 A query of the American College of Surgeons Trauma Quality Improvement Program has also suggested that patients presenting on DOACs are less likely to undergo neurosurgical procedures and have lower mortality rates than those on warfarin. 18 The rapid onset and offset of DOACs and the improvement in protocols for nonspecific hemostatic reversal of DOACs may account for some of the advantages over the longer lasting effects of warfarin.…”

Section: Discussionmentioning

confidence: 99%

Newer and Better? Comparing Direct Oral Anticoagulants to Warfarin in Patients With Traumatic Intracranial Hemorrhage

Billings

Khan

McVicker

et al. 2020

The American Surgeon™

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Background Direct oral anticoagulants (DOACs) have overtaken warfarin as the preferred anticoagulants for stroke prevention with atrial fibrillation and for treatment of venous thromboembolism. Despite the increased prevalence of DOACs, literature studying their impact on trauma patients with intracranial hemorrhage (ICH) remains limited. Most DOAC reversal agents have only been recently available, and concerns for worse outcomes with DOACs among this population remain. This study aims to assess the outcomes of patients with traumatic ICH taking DOACs compared with those taking warfarin. Methods A retrospective analysis of patients with traumatic ICH over a 5-year period was conducted. Demographics, injury severity, medication, and outcome data were collected for each patient. Patients taking warfarin and DOACs were compared. Results 736 patients had traumatic ICH over the study period, 75 of which were on either DOACs (25 patients) or warfarin (50 patients). The median age of the anticoagulated patients was 78 years; 52% were female, and 91% presented secondary to a fall. DOACs were reversed at close to half the rate of warfarin (40% vs 77%; P = .032). Despite this, the 2 groups had similar rates of worsening examination, need for operative intervention, and in-hospital mortality. In the follow-up, fewer patients taking DOACs had died at 6-months postinjury compared with those taking warfarin (8% vs 30%; P = .041). Discussion Despite DOACs being reversed at nearly half the rate of warfarin, patients presenting with traumatic ICH on warfarin had higher 6-month mortality suggesting a potential survival advantage for DOACs over warfarin in this population.

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“…There has been increasing interest in this topic, as the use of direct oral anticoagulant (DOAC) therapy is becoming more widespread. Prospective studies [ 18 , 19 , 20 , 21 , 22 , 23 , 24 ] and literature reviews [ 25 , 26 , 27 ] have demonstrated a higher safety profile for intracranial hemorrhage (ICH) following an MHI in patients treated with DOAC rather than those treated with vitamin K antagonists (VKAs). The advantage of this new class of anticoagulants in elderly patients [ 28 , 29 ] has also been determined.…”

Section: Introductionmentioning

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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Direct Oral Anticoagulant Treatment and Mild Traumatic Brain Injury: Risk of Early and Delayed Bleeding and the Severity of Injuries Compared with Vitamin K Antagonists

Cited by 40 publications

References 23 publications

Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis

Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis

Newer and Better? Comparing Direct Oral Anticoagulants to Warfarin in Patients With Traumatic Intracranial Hemorrhage

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

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