Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study

Abstract

alls resulting in a head injury are common among older adults. 1,2 Advanced age and anticoagulation are thought to be associated with an increased risk of intracranial hemorrhage (ICH) after a head injury. [3][4][5] With the aging population and increasing use of anticoagulants, older patients on anticoagulation are commonly seen in the emergency department after a head injury. The Canadian CT Head Rule suggests that patients presenting to the emergency department with a minor head injury who are older than 65 years should undergo head imaging to rule out ICH. 6 This clinical decision tool did not include patients on anticoagulation; however, a clinical policy from the American College of Emergency Physician suggests computed tomography (CT) imaging for these patients. 7 Before 2010, warfarin, a vitamin K antagonist, was the oral anticoagulant used most commonly in North America. Since then, direct oral anticoagulants (DOACs) have been approved for various indications including treatment of venous thromboembolism, prevention of venous thromboembolism after arthroplasty, and stroke prophylaxis in patients with atrial fibrillation. Unlike warfarin, DOACs either directly inhibit clotting factors II (e.g., dabigatran) or X (e.g., apixaban, rivaroxaban, edoxaban). Although more expensive than warfarin, DOACs are attractive alternatives

Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department

“…We found warfarin use was associated with a significantly increased odds of delayed intracranial hemorrhage within 90 days of an initial head injury compared to not using anticoagulants, while direct oral anticoagulant use was not associated with delayed intracranial hemorrhage. In our previous study, [15] we found warfarin was associated with an increased risk of intracranial hemorrhage on the index ED visit after a head injury compared to both no anticoagulation and direct oral anticoagulant use. We did not find a difference in the risk of intracranial hemorrhage in patients using a direct oral anticoagulant compared to no anticoagulation.…”

“…This was a planned subgroup analysis of a larger study that compared the risk of intracranial hemorrhage in elderly anticoagulated patients 65 years and older seen in the ED with a head injury [15]. We conducted a cohort study using population-based administrative data from 2016 to 2018 from Ontario, Canada that were held at Ontario Health.…”

Risk of both intracranial hemorrhage and ischemic stroke in elderly individuals with nonvalvular atrial fibrillation taking direct oral anticoagulants compared with warfarin: Analysis of the ANAFIE registry

“…27 Of 77,834 patients with head injury in a retrospective cohort study, including 9214 patients taking DOACs and 3703 patients taking warfarin, patients taking DOACs were reported to have a 30% lower risk of ICH than those taking warfarin. 28 Subdural/epidural hemorrhage was the most common subtype (0.32/100 person-years) among the three subtypes of ICH in the ANAFIE Registry. As this type of hemorrhage mainly results from a tear in the veins bridging the meninges due to head injury even if the injury is trivial and subclinical, it often occurs in elderly populations with a high risk of fall.…”

Performance of a provincial prehospital trauma triage protocol: A retrospective audit

“…Additional criteria, such as external signs of head trauma or antiplatelet medications, have been suggested to improve the sensitivity of triage tools. 29,30 Historically, the performance of prehospital trauma triage protocols was solely based on their capacity to distinguish severely injured patients from those who sustained minor injuries. However, the definition of severe trauma varies widely in the literature, and up to 14 indicators have been described.…”

“…Additional criteria, such as external signs of head trauma or antiplatelet medications, have been suggested to improve the sensitivity of triage tools. 29,30…”