Incremental Risk of Intracranial Hemorrhage After Mild Traumatic Brain Injury in Patients on Antiplatelet Therapy: Systematic Review and Meta-Analysis

Fiorelli, Elisa Maria; Bozzano, Viviana; Bonzi, Mattia; Rossi, Silvia; Colombo, G; Radici, Gaia; Canini, T; Kurihara, Hayato; Casazza, Giovanni; Solbiati, Monica; Costantino, Giorgio

doi:10.1016/j.jemermed.2020.07.036

Cited by 18 publications

(8 citation statements)

References 29 publications

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“…In mild TBI patients treated with APAs, two meta-analyses have demonstrated a small increased risk of immediate ICH, especially if concomitant with another risk factor for ICH such as GCS < 15 or age > 65 years [ 363 ] and a very low risk of delayed ICH [ 364 ], respectively. However, the subgroup of patients on dual antiplatelet therapy had an increased delayed bleeding risk, compared with single APA patients [ 364 ].…”

Section: Resultsmentioning

confidence: 99%

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

et al. 2023

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Background Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. Results This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. Conclusion A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

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Section: Resultsmentioning

confidence: 99%

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

et al. 2023

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“…28 Two meta-analyses revealed that pre-injury use of APT was associated with an increased incidence of tICH after mTBI. No difference was found in the composite outcome of mortality and neurosurgery 11,47 These findings, however, should be interpreted with caution given the wide variability in the incidence of ICH among studies and methodological flaws of several included studies.…”

Section: Discussionmentioning

confidence: 62%

Mild Traumatic Brain Injury in Elderly Patients Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis

Santing

Lee

Naalt

et al. 2022

Journal of Neurotrauma

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The aim of this work was to conduct a systematic review and meta-analysis of studies reporting on the risk of traumatic intracerebral hemorrhage (tICH), the course of tICH, and its treatment and mortality rates in elderly mild traumatic brain injury (mTBI) patients using direct oral anticoagulants (DOACs). We consulted PubMed and Embase for relevant cohort and case-control studies with a control group. Two authors independently selected studies, assessed methodological quality, and extracted outcome data. Estimates were pooled with the Mantel-Haenszel random-effects method. We identified 16 articles comprising 3671 elderly mTBI patients using DOACs. Use of DOACs was associated with a reduced risk of tICH compared to the use of vitamin K antagonists (VKAs; odds ratio [OR], 0.44; 95% confidence interval [CI], 0.29-0.65; I 2 = 22%) and a similar risk compared to the use of antiplatelet therapy (APT; OR, 0.98; 95% CI, 0.39-2.44; I 2 = 0%). Reversal agent use and neurosurgical intervention rate were lower in patients using DOACs compared to patients using VKAs (OR, 0.10; 95% CI, 0.06-0.16; I 2 = 0% and OR, 0.37; 95% CI, 0.21-0.67; I 2 = 0%, respectively). There was no significant difference in neurosurgical intervention rate between patients who used DOACs versus patients who used APT (OR, 0.58; 95% CI, 0.15-2.21; I 2 = 41%) or no antithrombotic therapy (OR, 0.76; 95% CI, 0.20-2.86; I 2 = 23%). ICH progression, risk of delayed ICH, and TBI-related in-hospital mortality were comparable among treatment groups. The present study indicates that elderly patients using DOACs have a lower risk of adverse outcome compared to patients using VKAs and a similar risk compared to patients using APT after mTBI.

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“…The National Institute for Health and Care Excellence guidelines of the UK report that scientific data are insufficient to provide recommendations on the management of these patients. A recent meta-analysis has demonstrated a small increased risk of immediate ICH in MTBI patients on antiplatelet therapy, especially if concomitant with another risk factor for ICH such as GCS < 15 or age > 65 years [ 34 ]. No guideline recommendations exist for routine repeated CT scans in MTBI patients on antiplatelet therapy, since the literature on this topic is very scant.…”

Section: Discussionmentioning

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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Incremental Risk of Intracranial Hemorrhage After Mild Traumatic Brain Injury in Patients on Antiplatelet Therapy: Systematic Review and Meta-Analysis

Cited by 18 publications

References 29 publications

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

Mild Traumatic Brain Injury in Elderly Patients Receiving Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis

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

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