Antiplatelet and anticoagulant agents have minimal impact on traumatic brain injury incidence, surgery, and mortality in geriatric ground level falls: A multi-institutional analysis of 33,710 patients

Abstract

BACKGROUND Falls are the leading cause of traumatic brain injury (TBI) and TBI-related deaths for older persons (age, ≥65 years). Antiplatelet and/or anticoagulant therapy (antithrombotics [ATs]) is generally felt to increase this risk, but the literature is inconsistent. The purpose of this study was to determine the impact of AT use on the rate, severity, and outcomes of TBI in older patients following ground level falls. METHODS Ground level fall patients from 90 hospitals’ trauma registries were selected. Patients were excluded if younger than 65 years or had an Abbreviated Injury Scale score of >2 in a region other than head. Electronic medical record data for preinjury AT therapy were obtained. Patients were grouped by regimen for no AT, single, or multiple agents. Groups were compared on rates of diagnosed TBI, TBI surgery, and mortality. RESULTS There were 33,710 patients (35% male; mean age, 80.5 years; mean Glasgow Coma Scale, 14.6), with 47.6% on single or combination AT therapy. The proportion of patients with TBI diagnoses did not differ between those on no AT (21.25%) versus AT (21.61%; p = 0.418). Apixaban (15.7%; p < 0.001) and rivaroxaban (13.19%; p = 0.011) were associated with lower rates of TBI, and acetylsalicylic acid-clopidogrel was associated with a higher TBI rate (24.34%; p = 0.002) versus no AT. acetylsalicylic acid-clopidogrel was associated with a higher cranial surgery rate (2.9%; p = 0.006) versus no AT (1.96%), but surgery rates were similar for all other regimens. No regimen was associated with higher mortality. CONCLUSION In this large multicenter study, the intake of ATs in older patients with ground level falls was associated with inconsistent effects on risk of TBI and no significant increases in mortality, indicating that AT use may have negligible impact on patient clinical management. A large, confirmatory, prospective study is needed because the commonly held belief that ATs uniformly increase the risk of traumatic intracranial bleeding and mortality is not supported. LEVEL OF EVIDENCE Therapeutic/care management, level II.

Rapid detection of platelet inhibition and dysfunction in traumatic brain injury: A prospective observational study

“… 20 , 21 In fact, a large multicenter prospective observational study suggests that taking antithrombotic medication may not worsen outcomes in TBI in a similar patient cohort to the present analysis. 2 …”

“…20,21 In fact, a large multicenter prospective observational study suggests that taking antithrombotic medication may not worsen outcomes in TBI in a similar patient cohort to the present analysis. 2 In theory, testing platelet function of patients with tICH upon arrival in the trauma bay is a reasonable strategy to shepherd a valuable resource and improve outcomes. This approach may also be useful to identify patients on aspirin or P2Y12 inhibitors for whom medication history is not available at the time of presentation.…”

“…Use of antiplatelet medication may be an independent risk factor for the development of intracranial hemorrhage in patients presenting with blunt head injury. 1 , 2 It is, therefore, important to ascertain the history of antiplatelet medication use, because it may affect patient outcomes and guide clinical management. However, medication history is frequently unknown in patients who present with traumatic brain injury (TBI) or cannot be determined in a timely fashion.…”

Current Trends in Mild Traumatic Brain Injury

“…Deterioration is reported to be more common in the elderly; potentially due to the larger subdural space and delayed hyperemia and hyperperfusion [ 31 ]. Prevalent usage of anticoagulant and antiplatelet medications in the elderly was commonly deemed as culprits for this deterioration, but current evidence suggests otherwise [ 32 , 33 ]. Reasons for these conflicting data remain unclear.…”

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

“…We have previously reported that trauma energy level could be explored as a potential rule-out criterion in otherwise healthy patients < 60 years [1]. Fakhry et al [23] reviewed over 33.000 geriatric patients with ground-level falls in a trauma registry. They concluded that neither DOAC-therapy nor APT conferred an elevated risk of TICH except for an elevated incidence of TICH in patients on aspirin-clopidogrel combination therapy [23].…”