Incidence of Intracranial Hemorrhage and Outcomes after Ground-level Falls in Geriatric Trauma Patients Taking Preinjury Anticoagulants and Antiplatelet Agents

Abstract

Antiplatelet and anticoagulant medication increases the risk of intracranial hemorrhage (ICH) after a fall in geriatric patients. We sought to determine whether there were differences in ICH rates and outcomes based on type of anticoagulant or antiplatelet agent after a ground-level fall (GLF). Our institutional trauma registry was used to identify patients 65 years old or older after a GLF while taking warfarin, clopidogrel, or aspirin over a 2-year period. Rates and types of ICH and patient outcomes were evaluated. Of 562 patients who met inclusion and exclusion criteria, 218 (38.8%) were on warfarin, 95 (16.9%) were on clopidogrel, and 249 (44.3%) were on aspirin. Overall ICH frequency was 15 per cent with no difference in ICH rate, type of ICH, need for craniotomy, mortality, or intensive care unit or hospital length of stay between groups. Patients with ICH were more likely to present with abnormal Glasgow Coma Score, history of hypertension, and/or loss of consciousness.

Predictive factors of intracranial bleeding in head trauma patients receiving antiplatelet therapy admitted to an emergency department

“…The following parameters are routinely recorded in RATED: patient’s baseline characteristics; clinical status including any coexisting or underlying conditions; bleeding risk factors described in the literature (age, previous stroke, previous gastrointestinal bleeding, renal impairment, anemia, thrombocytopenia, liver disease, cancer, hypertension, dementia, alcohol) [ 25 – 28 ], and the use of antiplatelet therapy; use of CT scan or ultrasound; laboratory data at baseline; the antithrombotic treatment (indication, time duration, drugs, doses); concomitant drugs; death during hospitalization. For this study, we focused on the intracranial bleeding predictive factors that are already known: age, history of major bleeding (history of bleeding leading to transfusion, bleeding in a critical area and bleeding leading to hemodynamic instability by taking into account the patient history during the different hospital stay), anemia (defined as a hemoglobin count < 12 g/dl in women and < 13 in men), thrombocytopenia (defined as a platelet count < 150 G/l), renal failure, alcohol intake, neurological examination, Glasgow coma scale, headache or vomiting, loss of consciousness, and amnesia [ 14 , 21 , 24 , 25 ]. Radiological severity was evaluated by calculating the Rotterdam CT score on the first scan performed in the emergency room as follows: (a) status of basal cisterns subdivided into normal (0), compressed (1), or absent (2); (b) midline shift subdivided into 0-5 mm (0) or > 5 mm (1); (c) epidural hematoma subdivided into present (0) or absent (1); (d) traumatic subarachnoid hemorrhage or intraventricular hemorrhage subdivided into absent (0) or present (1) [ 29 , 30 ].…”

“…For the other guidelines, however, antiplatelet agents are not listed as ICH risk factors [ 22 , 23 ]. Some authors have attempted to define predictive factors for cerebral bleeding, like the Glasgow coma scale, loss of consciousness, headache or vomiting, yet most included patients taking anticoagulants or antiplatelets [ 14 , 15 , 24 ].…”

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

“…To date, specific recommendations are missing for low‐energy trauma in older patients such as ground‐level falls with or without anticoagulation or antiplatelet treatments and equivocal clinical signs of traumatic brain injury. Current studies on these particular patients are heterogeneous and bear some limitations, such as missing control group, small sample sizes, or lacking information about injury severity …”

Athletes and blood clots: individualized, intermittent anticoagulation management

“…Some evidence suggests that individuals who sustain trauma while routinely taking NSAIDs are at increased risk of bleeding complications . In a study of geriatric patients who sustained falls, the risk of developing intracranial hemorrhage among those treated with warfarin was not significantly different to those taking aspirin . How bleeding risk after trauma compares between athletes taking NSAIDs and those with sub‐therapeutic plasma DOAC levels at the time of competition is unknown.…”