Risk of Delayed Intracerebral Hemorrhage in Anticoagulated Patients after Minor Head Trauma: The Role of Repeat Cranial Computed Tomography

Swap, Clifford J.; Sidell, Margo; Ogaz, Raquel; Sharp, Adam L.

doi:10.7812/tpp/15-095

Cited by 36 publications

(27 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…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.…”

Section: Discussionmentioning

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

View full text Add to dashboard Cite

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.

show abstract

Section: Discussionmentioning

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

View full text Add to dashboard Cite

show abstract

“…Rates of immediate traumatic intracranial hemorrhage following a traumatic injury identified by head CT scan vary in the literature, ranging from 5.1–29.1% [ 7 – 13 ]. In the event that an immediate intracranial hemorrhage has been ruled out, delayed intracranial hemorrhage (DICH) among injured elderly patients on ACAP therapy still remains a concern [ 14 , 15 ].…”

Section: Introductionmentioning

confidence: 99%

“…In the event that an immediate intracranial hemorrhage has been ruled out, delayed intracranial hemorrhage (DICH) among injured elderly patients on ACAP therapy still remains a concern [ 14 , 15 ]. Prior studies have concluded that rates of DICH in elderly injured patients on pre-injury ACAP medications are low, ranging from 0 to 6% [ 8 , 9 , 13 , 16 – 19 ]. Most of these analyses have considered limited panels of ACAP medications and have not addressed patients taking multiple ACAP medications.…”

Section: Introductionmentioning

confidence: 99%

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

et al. 2018

View full text Add to dashboard Cite

BackgroundFalls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy.MethodsData from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported.ResultsData on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications.ConclusionsUniversal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.

show abstract

“…6 Another study that included patients on clopidogrel and warfarin had a longer follow-up window of 60 days and found readmissions for symptomatic hemorrhage up to 54 days. 7 Underreporting is also possible, as death from such a complication would cause loss to followup. Different characteristics have been suggested as potential risk factors for these significantly delayed ICH presentations, such as international normalized ratio .3, mechanism of trauma, and patient age, but there is no consensus thus far.…”

mentioning

confidence: 99%

“…Different characteristics have been suggested as potential risk factors for these significantly delayed ICH presentations, such as international normalized ratio .3, mechanism of trauma, and patient age, but there is no consensus thus far. 4,5,7,8 Another point made in multiple articles on this topic is that there is a false-negative rate of approximately 2% on head CT reports in the ED 9 and some of the readmissions fell into this category.…”

mentioning

confidence: 99%

Head injury while on anticoagulation

Nearing

Tsao

2017

Neur Clin Pract

View full text Add to dashboard Cite

reatment of mild traumatic brain injury (mTBI)/concussion is usually handled by emergency medicine and primary care physicians or the injured person might not seek medical care. When a patient is evaluated, imaging may not be not required if the neurologic examination is normal. However, if there are focal neurologic deficits, vomiting, headache, coagulopathy, age .60 years, outward evidence of head or neck trauma, intoxication, or a dangerous mechanism of trauma, then head CT or brain MRI is recommended. In situations where a patient has an initially negative head CT without any residual signs or symptoms, discharge from the emergency department (ED) is considered safe. However, this is not the case for patients on anticoagulation-immediate discharge from ED after a normal head CT may not be appropriate. 1 Traumatic brain injury (TBI) affects more than 1.7 million Americans yearly, and the proportion of Americans on anticoagulation is increasing (prescriptions at outpatient visits are up 38% from 2009 to 2014), so that more physicians are being faced with this dilemma without much literature to guide them. 2,3 Due to unknown rates of delayed intracranial hemorrhage (ICH), providers typically err on the side of caution and allow for a prolonged period of observation and obtain repeat head imaging. The utility of this practice is examined in this issue of Neurology ® Clinical Practice by Campiglio et al. 4 The authors retrospectively examine data in one center where the practice includes 48 hours of observation and a follow-up head CT. They found that among 284 patients on anticoagulation who had an initial CT that did not demonstrate hemorrhage, only 4 had hemorrhage on follow-up CT (1.4%), and not one of these was clinically significant. The article also points out that the cost for each hospitalization was approximately €654 in Europe and $8,152 in the United States. This study brings up the important point that it may not be financially prudent to observe all such patients and repeat scans. With a growing elderly population and a growing portion of them on anticoagulation, this is an extra expense our health care system could do without. It also informs clinical practice in that most patients on anticoagulation who have a fall from standing have a low likelihood of delayed ICH and lower likelihood of requiring neurosurgical intervention. The authors conclude that it is safe to discharge mTBI patients on anticoagulation after a negative head CT. This study does not fully address that question for the following reasons. The number of participants is limited and the population is homogenous, composed mostly of patients who had falls rather than motor vehicle accidents or other traumas. Rates of hemorrhage as high as 6% have been reported within a 24-hour observation window in a small See page 296

show abstract

Risk of Delayed Intracerebral Hemorrhage in Anticoagulated Patients after Minor Head Trauma: The Role of Repeat Cranial Computed Tomography

Cited by 36 publications

References 11 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

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

Head injury while on anticoagulation

Contact Info

Product

Resources

About