Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use

Abstract

Study Objective Patients on warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage (tICH) following blunt head trauma. The prevalence of immediate tICH and the cumulative incidence of delayed tICH in these patients, however, are unknown. Methods A prospective, observational study at two trauma centers and four community hospitals enrolled emergency department (ED) patients with blunt head trauma and pre-injury warfarin or clopidogrel use from April 2009 through January 2011. Patients were followed for two weeks. The prevalence of immediate tICH and the cumulative incidence of delayed tICH were calculated from patients who received an initial cranial computed tomography (CT) in the ED. Delayed tICH was defined as tICH within two weeks following an initially normal CT scan and in the absence of repeat head trauma. Results A total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients [34.2%] from Level 1 or 2 trauma centers and 700 patients [65.8%] from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics although concomitant aspirin use was more prevalent among patients on clopidogrel. The prevalence of immediate tICH was higher in patients on clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4-16.4%) than patients on warfarin (37/724, 5.1%; 95%CI 3.6-7.0%), relative risk 2.31 (95%CI 1.48-3.63). Delayed tICH was identified in 4/687 (0.6%; 95%CI 0.2-1.5%) patients on warfarin and 0/243 (0%; 95%CI 0-1.5%) patients on clopidogrel. Conclusion While there may be unmeasured confounders that limit intergroup comparison, patients on clopidogrel have a significantly higher prevalence of immediate tICH compared to patients on warfarin. Delayed tICH is rare and occurred only in patients on warfarin. Discharging patients on anticoagulant or antiplatelet medications from the ED after a normal cranial CT scan is reasonable but appropriate instructions are required as delayed tICH may occur.

Improving professional practices: the management of patients treated by anticoagulants and victims of a head injury

“…Ces patients nécessitent donc une surveillance attentive, d'autant plus qu'il a été montré la possibilité de mise en évidence d'un saignement intracrânien à distance du traumatisme, malgré un examen tomodensitométrique (TDM) cérébral initial normal. La proportion de malades ayant présenté une hémorragie retardée variait selon les études entre 0,6 et 6 % [6,7].…”

Premorbid Use of Clopidogrel Portends Worse Outcomes in Patients Treated Surgically for Intracranial Hemorrhage

“…However, the initiation of surgical evacuation also involves consideration of the natural history of intracranial hemorrhage, and an understanding of the patient's overall prognosis. Regarding ICH, recent investigations have addressed issues such as risk for hematoma expansion [13] [18]- [20], outcomes of intracranial hemorrhage in patients taking APACs [6]- [10] and differences in said outcomes between the various types of antithrombotics [10] [21]- [25]. These studies were performed primarily with regard to stroke, emergent care and care in a trauma setting, not to neurosurgical intervention.…”

Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls

“…10 Traumatic brain injury in anticoagulated patients occurs not only acutely but can also develop more slowly and be identified in a delayed fashion. 11,12 Aggressive reversal of anticoagulation has been shown to improve outcome after traumatic intracranial hemorrhage (ICH). 13 Options for reversal of anticoagulation include infusion of fresh frozen plasma (FFP), administration of vitamin K, and use of coagulation factors.…”