Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study

Abstract

Background:The number of trauma patients on prehospital novel oral anticoagulants (NOACs) is increasing. After an initial negative computed tomography of the head (CTH), practice patterns are variable for obtaining repeat CTH to evaluate for delayed intracranial hemorrhage (ICH-d). However, the risks and outcomes of ICH-d for patients on NOACs are unclear. We hypothesized that for these patients, the incidence of ICH-d is low, similar to that of warfarin, and when it occurs, does not result in clinically significant worse outcomes. Methods: Five Level-1 trauma centers in Northern California participated in a retrospective review of anticoagulated trauma patients. Patients were included if their initial CTH was negative. Primary outcomes were incidence of ICH-d, neurosurgical intervention, and death. Patient factors associated with the outcome of ICH-d were determined by multivariable regression. Results: From 2016 to 2018, 777 patients met inclusion criteria (NOAC: n=346; warfarin: n=431), 54% of whom received a repeat CTH. ICH-d incidence was 2.3% in the NOAC group and 4% in the warfarin group (p=0.31). No NOAC patient with ICH-d required neurosurgical intervention or died because of their head injury. Two warfarin patients received neurosurgical intervention and three died from their head injury. Head Abbreviated Injury Scale ≥ 3 was associated with increased odds of developing ICH-d (aOR 32.70, p<0.01). Conclusion:The incidence of ICH-d in patients taking NOAC is low. In this study, patients on NOACs who developed ICH-d after an initial negative CTH did not need neurosurgical

Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis

“…A higher rate of delayed ICH in DOAC patients was also seen in several smaller studies. 13,19,20 This is in direct contrast with results from the largest study of DOAC patients (n ¼ 346) by Cohan and associates, 21 which found the risk of delayed ICH to be lower than the risk in 431 patients on warfarin (1.2% vs 2.3%). A higher rate of delayed ICH in patients anticoagulated with warfarin compared with DOACs was also seen in several smaller retrospective and prospective observational studies.…”

“…A higher rate of delayed ICH in patients anticoagulated with warfarin compared with DOACs was also seen in several smaller retrospective and prospective observational studies. 1,14,[21][22][23][24] Our systematic review of 3,051 patients on DOAC or warfarin found the pooled, weighted rate of delayed ICH to be similarly low in patients on DOACs compared with those on warfarin (2.43% vs 2.31%). There was low clinical and statistical heterogeneity between studies.…”

“…The higher rate of delayed ICH in patients on warfarin may have been due to a larger percentage of patients with elevated INR. Unlike warfarin, DOAC medications have no easily discernable measure 22 Barmparas et al 2018 17 Battle et al 2011 13 Bauman et al 2017 1 Chenoweth et al 2018 9 Cipriano et al 2018 19 Cocca et al 2019 18 Cohan et al 2020 21 Mann et al 2018 20 Marques et al 2019 23 Riccardi et al 2017 14 Turcato et al 2019 24 Type of study 22 Barmparas et al 2018 17 Battle et al 2011 13 Bauman et al 2017 1 Chenoweth et al 2018 9 Cipriano et al 2018 19 Cocca et al 2019 18 Cohan et al 2020 21 Mann et al 2018 20 Marques et al 2019 23 Riccardi et al 2017 14 Turcato et al 2019 24 Outcomes/ conclusions Delayed ICH, n (%) of anticoagulation degree, so risk factors for developing delayed ICH in these patients are even more elusive.…”

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

“…Thirteen studies including 3143 patients assessed the rate of a neurosurgical intervention in elderly patients with tICH after mTBI. [21][22][23]25,[27][28][29][30][31][32][33][34][35] Patients using DOACs received less often a neurosurgical intervention compared to patients using VKAs (13 studies; OR, 0.37; 95% CI, 0.21-0.67), with no evidence of heterogeneity (I 2 = 0%, random effect; Fig. 3A).…”

“…Of these 17 articles, two were based on the same study results, 20,35 and two were partly based on the same study results. 25,26 Duplicate results were only used once for the meta-analysis (Fig. 1).…”