Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists

Abstract

Prognosis after mild traumatic brain injury (MTBI) on oral anticoagulant therapy (OAT) is uncertain. We evaluated the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) and the safety of a clinical management protocol. In this single-center prospective observational study, we enrolled 220 patients on OAT with MTBI. After a first negative CT scan, asymptomatic patients underwent a close neurological observation; if neurologically stable, they were discharged without a second CT scan and followed up for 1 month. Out of the 220 patients, 206 met the inclusion criteria. 23 of them (11.2%) had a positive first CT scan for ICH. Only 1 (0.5%, 95% CI 0.0-1.4%) died because of ICH; no one required neurosurgical intervention. The observed prevalence rate of immediate ICH resulted statistically higher in VKAs-treated patients compared to those treated with DOACs (15.7 vs. 4.7%, RR 3.34, 95% CI 1.18-9.46, P < 0.05). In the 1-month follow-up, 5 out of the 183 patients with a negative CT scan were lost. Out of the remaining 178 patients, only 3 showed a delayed ICH (1.7%, 95% CI 0.0-3.6%), 1 of them died (0.6%, 95% CI 0.5-1.7%) and the others did not require neurosurgical intervention. DOACs resulted safer than VKAs also in the setting of MTBI. In our observation, the rate of delayed hemorrhage was relatively low. Patients presenting with a negative first CT scan and without neurological deterioration could be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan.

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

“…In adults, observation has been shown to be as effective as the CT in the presence of a caregiver and a patient able to understand home instructions [ 46 ]. Our results show similar percentages of positive second CTs of the brain as previous studies [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ]. In addition, even our patients who tested positive for the second CTs did not require surgery, as another study showed.…”

“…Patient management for those on VKAs and DOAC does not differ, and the observation period is 24 h. This involves resource utilization and a longer stay in ED, as demonstrated by the long LOS ( Table 3 ). However, the need for a control head CT scan in patients on anticoagulation therapy that do not display neurological deterioration is disputable, since the incidence of late ICH is between 0 and 7% [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ]. Some countries, such as Italy, have guidelines stating that all anticoagulated patients who have undergone a head CT should be observed for 24 h and have a repeat CT before discharge; others suggest discharge only after observation or observation in the community.…”

“…Despite specialist emergency care, mortality is reportedly high, with up to 34% dying in hospitals [ 49 , 67 , 68 , 69 ]. The problem of LOS is well recorded in the literature, and some authors have proposed that patients on anticoagulant therapy may be discharged if the admission CT does not reveal an ICH, provided that they are accompanied by a caregiver and are informed about red flags [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ].…”

“…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.…”

A focus on direct oral anticoagulants: “old” and possible new indications and efforts for a better clinical management

“…Prognosis after mild traumatic brain injury (MTBI) on OACs is uncertain. In the article entitled "Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists", Alessandro Cipriano and colleagues [8] evaluate the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) and the safety of a clinical management protocol in a single-center prospective observational study, enrolling 220 patients on OACs with MTBI. As expected, DOACs are safer than VKAs also in the setting of MTBI.…”