Delayed intracranial hemorrhage after head trauma in patients on direct-acting oral anticoagulants

Smith, Anthony W.; Wrenn, Keith; Barrett, Tyler W.; Jones, Ian D.; Rohde, John Paul; Slovis, Corey M.; Russ, Stephan; Self, Wesley H.

doi:10.1016/j.ajem.2016.08.024

Cited by 12 publications

(3 citation statements)

References 10 publications

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“…Sheer injury or concussion can also present with AMS. Though rare, delayed presentations of intracranial hemorrhage can occur 46 and meningitis can present later as a result of facial or skull fractures.…”

Section: Traumamentioning

confidence: 99%

Altered Mental Status in the Emergency Department

Smith

Han

2019

Semin Neurol

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Altered mental status is an umbrella term that covers a broad spectrum of disease processes that vary greatly in chronicity and severity. Causes can be a primary neurologic insult or a result of a systemic illness resulting in end-organ dysfunction of the brain. Acute changes in mental status are more likely than chronic changes to be immediately life-threatening and are therefore the focus of this review. Given the potential time-sensitive nature, acute changes in mental status must be addressed immediately and with urgency. We recommend a primary survey followed by a secondary survey with special attention to immediate life-threatening reversible causes. We then recommend a systems-based approach searching for any other life-threatening or reversible causes. Because the differential for altered mental status is broad, a comprehensive emergency department evaluation including a detailed history and physical exam as well as laboratory and radiographic testing is needed.

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Section: Traumamentioning

confidence: 99%

Altered Mental Status in the Emergency Department

Smith

Han

2019

Semin Neurol

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“…A relevant reason for this might be the combination between the widespread use of oral anticoagulation (OAC) [ 5 , 6 ] and the high risk of falling in these patients, which is known to cause serious injuries even in low-energy trauma [ 2 ]. The influence of oral anticoagulation in the pre-trauma scenario has already been investigated in several studies for head mono trauma [ 7 , 8 , 9 , 10 ] but with partly contradicting findings.…”

Section: Introductionmentioning

confidence: 99%

Influence of Oral Anticoagulation and Antiplatelet Drugs on Outcome of Elderly Severely Injured Patients

Kerschbaum

Henssler

Ernstberger

et al. 2021

JCM

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Introduction: Severely injured elderly patients have a poorer prognosis and higher mortality rates after severe trauma compared with younger patients. The aim of this study was to correlate the influence of pre-existing oral anticoagulation (OAC) and antiplatelet drugs (PAI) on the outcome of severely injured elderly patients. Methods: Using a prospective cohort study model over an 11-year period, severely injured elderly patients (≥65 years and ISS ≥ 16) were divided into two groups (no anticoagulation/platelet inhibitors: nAP and OAC/PAI). A comparison of the groups was conducted regarding injury frequency, trauma mechanism, severity of head injuries, and medication-related mortality. Results: In total, 254 out of 301 patients were analyzed (nAP: n = 145; OAC/PAI: n = 109, unknown data: n = 47). The most relevant injury was falling from low heights (<3 m), which led to a significantly higher number of severe injuries in patients with OAC/PAI. Patients with pre-existing OAC/PAI showed a significantly higher overall mortality rate compared to the group without (38.5% vs. 24.8%; p = 0.019). The severity of head injuries in OAC/PAI was also higher on average (AIS 3.7 ± 1.6 vs. 2.8 ± 1.9; p = 0.000). Conclusion: Pre-existing oral anticoagulation and/or platelet aggregation inhibitors are related to a higher mortality rate in elderly polytrauma patients. Low-energy trauma can lead to even more severe head injuries due to pre-existing medication than is already the case in elderly patients without OAC/PAI.

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“…As such, the use of antithrombotics, such as antiplatelet agents, warfarin, or novel oral anticoagulants (NOACs), has also increased. 1,[5][6][7][8][9][10] Several studies have suggested that patients taking antithrombotic medications have an increased risk of intracranial hemorrhage (ICH) after blunt head trauma. Elderly patients are more susceptible to falls, which puts them at risk for head injury.…”

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confidence: 99%

Utility of Repeat Head CT in Patients on Preinjury Antithrombotic Medications

Marcia

Moazzez

Plurad

et al. 2018

The American Surgeon

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Presently, there are no standardized guidelines regarding the necessity or timing of repeat head imaging in patients on antithrombotics (antiplatelet agents, warfarin, or novel oral anticoagulants) with suspected traumatic brain injury. This is a two-year single institutional retrospective analysis of patients with suspected traumatic brain injury on antithrombotic medications. Patients with a stable or negative repeat head CT were compared with patients who developed a new bleed or demonstrated progression of intracranial hemorrhage (ICH). Of 110 patients, 55 patients (50%) had a positive initial CT, two patients (1.8%) developed a new bleed after initially normal head CT, and 21 patients (19.1%) demonstrated worsening ICH. Patients with worsening or delayed ICH had a higher median Injury Severity Score (14 vs 5, P < 0.001), higher head/neck and face Abbreviated Injury Severity scores (both P < 0.05), and were more likely to be receiving combination therapy with warfarin and clopidogrel (4.3% vs 0%, P = 0.05). On multivariate analysis, lower face and head/neck Abbreviated Injury Severity scores were associated with a decreased risk for delayed or worsening hemorrhage (odds ratio = 0.21 and 0.46, respectively, P < 0.05). Repeat head CT in patients on a preinjury antithrombotic has a low yield. The use of combination therapy may result in an increased risk for delayed hemorrhage or hemorrhage progression.

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Delayed intracranial hemorrhage after head trauma in patients on direct-acting oral anticoagulants

Cited by 12 publications

References 10 publications

Altered Mental Status in the Emergency Department

Altered Mental Status in the Emergency Department

Influence of Oral Anticoagulation and Antiplatelet Drugs on Outcome of Elderly Severely Injured Patients

Utility of Repeat Head CT in Patients on Preinjury Antithrombotic Medications

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