Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury

Markou, Markella; Pleger, Burkhard; Grözinger, Martin; Pintea, Bogdan; Hamsen, Uwe; Könen, Sabrina; Schildhauer, Thomas A.; Martínez, Ramón; Gousias, Konstantinos

doi:10.1007/s00068-019-01228-9

Cited by 8 publications

(12 citation statements)

References 22 publications

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“…No patients in the DOAC group required surgery. Although this correlated with other studies that have seen better outcomes for patients on DOAC than those on VKAs, other studies have demonstrated opposing results [ 35 , 36 , 37 ]. Larger studies are needed to shed light on this.…”

Section: Discussionsupporting

confidence: 83%

“…Recent studies, however, have shown conflicting data for patients on DOACs; this is in terms of higher risk for ICH, ICH progression, or death [ 23 , 24 ] and regarding hematoma expansion, mortality, and rates of operational intervention in patients on DOACs compared to VKAs [ 35 , 36 , 37 ]. Some recent studies have also caused doubts about the belief that anticoagulant use is predictive of traumatic intracranial hemorrhage (ICH) after adjusted analysis, especially by age [ 38 , 39 ].…”

Section: Introductionmentioning

confidence: 99%

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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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Section: Discussionsupporting

confidence: 83%

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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“…Seventy-five patients (55.5%) showed a favorable outcome (GOS 4 to 5) 1 month after ICH (►Table 3), whereas traumatic cause of ICH was associated with a better outcome (p ¼ 0.041). A more favorable outcome was further associated with younger age, smaller ICH volume at first CT scan, absence of dilated and fixed pupil or no CPR prior to or at admission, a higher GCS score at admission, no IVH or posthemorrhagic hydrocephalus, lower CCI, lower Marshall score, and absence of arterial hypertension in patients with traumatic ICH, as previously reported 27 and with absence of dilated and fixed pupil as well as a higher GCS score at admission in patients with spontaneous ICH. Of note, the Patients' mortality was estimated at 15.5 and 26.8% in patients with traumatic and nontraumatic ICH, respectively, whereas the treatment of more than half of them (53.8%) was limited to the best supportive treatment in line with their living will.…”

Section: Patient Outcomesupporting

confidence: 79%

“…The demographic and clinical categorical variables studied were gender (m/f); Glasgow Coma Scale (GCS) score at admission (13)(14)(15) 27 The following endpoints were recorded: patients' outcome assessed with the Glasgow Outcome Scale (GOS) 1 month after ICH (GOS: 1-5), surgical decision-making, HE (yes/no), LOS (ICU and hospital), as well as hospital costs. Favorable outcome was defined as GOS of 4 or 5 29 ; HE was defined as progressive 33% volume growth shown by a follow-up head CT scan routinely performed 4 to 6 hours after the initial CT scan or sooner in cases of clinical deterioration 30 .…”

Section: Methodsmentioning

confidence: 99%

“…Our conservative treatment was in line with the recent guidelines for traumatic and nontraumatic ICH. 13 14 Neuromonitoring was applied to intubated/sedated patients as reported by Markou et al 27 The surgical therapy comprised simple implantations of EVD, microsurgical ICH evacuations through decompressive hemicraniectomies, or microsurgical ICH evacuations through osteoplastic craniotomies 22 23 ( Fig. 1 ).…”

Section: Methodsmentioning

confidence: 99%

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Distinct Behavior of Traumatic versus Nontraumatic Intracerebral Hematomas: Different Biology or Impact of Age?

Gousias

Pleger

Markou

et al. 2021

J Neurol Surg A Cent Eur Neurosurg

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Background and Study Aims Patients with large intracerebral hematomas (ICH) may demonstrate different demographics and underlying brain and systemic diseases, as well as different radiologic courses and distinct outcomes. It remains unclear whether their different behavior attributes to a different biology of the ICH or to the asymmetric characteristics of the two populations. To analyze and adjust for potential sources of selection and treatment bias, our study compared age-matched patients with traumatic and nontraumatic ICH in a single cohort diagnosed and treated in the same surgical department. Material and Methods We analyzed 135 consecutive patients with traumatic (n = 90) or spontaneous ICH (n = 45) undergoing treatment at a surgical intensive care unit of an urban university hospital. We documented their differences before and after adjustment for age in terms of demographics, the therapies applied, their radiologic (i.e., volume and rate of ICH expansion [HE]) and clinical (patients' outcome at 30 days) course, the length of hospital and ICU stay, as well as the hospital costs. Results Patients with traumatic ICH demonstrated more favorable clinical and radiologic characteristics at admission, that is, higher Glasgow Coma Scale score (p < 0.001), less frequently dilated pupil (p = 0.028), lower Charlson Comorbidity Index (p < 0.001), smaller ICH volume (p < 0.001), noneloquent (p < 0.001) or nonintraventricular (p = 0.003) ICH locations, as well as underwent fewer neurosurgical interventions (p < 0.001) and showed a better outcome (p = 0.041), defined as Glasgow Outcome Scale 4 and 5. After adjustment for age, no different outcomes were observed. Of note, elderly patients on novel oral anticoagulants (NOACs) were more likely to develop an HE compared with those on vitamin K antagonists (VKAs, p = 0.05) after traumatic brain injury (TBI) but not after spontaneous ICH. Conclusion Our data reveal a significant heterogeneity within the traumatic series. Whereas younger patients show an excellent outcome, the elderly population of the traumatic cases demonstrates a poor outcome similar to that of the nontraumatic cohort. HE under NOACs rather than under VKAs is more likely in the elderly after TBI. Larger prospective trials are warranted to elucidate the potential individual underlying molecular mechanisms for the development of an ICH and HE in these diseases.

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Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls

Nederpelt

Naar

Meier

et al. 2022

Eur J Trauma Emerg Surg

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Introduction Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. Methods We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. Results A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15–0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36–7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15–2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06–1.87) compared to controls. Conclusion Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

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Intake of NOAC is associated with hematoma expansion of intracerebral hematomas after traumatic brain injury

Cited by 8 publications

References 22 publications

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

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

Distinct Behavior of Traumatic versus Nontraumatic Intracerebral Hematomas: Different Biology or Impact of Age?

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls

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