Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis

Abstract

Background The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients. Objective The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA. Methods A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death). Results Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23–1.52%), ranging from 0 to 4%, with substantial heterogeneity (I2 = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04). Conclusion Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

“…In mild TBI patients treated with APAs, two meta-analyses have demonstrated a small increased risk of immediate ICH, especially if concomitant with another risk factor for ICH such as GCS < 15 or age > 65 years [ 363 ] and a very low risk of delayed ICH [ 364 ], respectively. However, the subgroup of patients on dual antiplatelet therapy had an increased delayed bleeding risk, compared with single APA patients [ 364 ].…”

“…In mild TBI patients treated with APAs, two meta-analyses have demonstrated a small increased risk of immediate ICH, especially if concomitant with another risk factor for ICH such as GCS < 15 or age > 65 years [ 363 ] and a very low risk of delayed ICH [ 364 ], respectively. However, the subgroup of patients on dual antiplatelet therapy had an increased delayed bleeding risk, compared with single APA patients [ 364 ]. Another meta-analysis that included 20 observational studies comparing 2447 TBI patients on pre-injury APAs with 4814 controls revealed no statistically significant difference in early mortality, need for neurosurgery or LOS between the two groups, with similar results for subgroup analyses of aspirin and clopidogrel users [ 365 ].…”

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

“…55 Another meta-analysis showed a risk of dICH in mTBI patients using APT of 0.18%. 56 Therefore, the authors of these two studies concluded that, for most patients, discharge after an initial negative head CT is defendable. There is a lack of data on the need for observation or repeat CT head in elderly mTBI patients specifically using DOACs in case of a negative CT. We found no difference in the rate of dICH between elderly mTBI patients using DOACs compared to patients using APT or VKAs.…”

Does Antithrombotic Therapy Affect Outcomes in Major Trauma Patients? A Retrospective Cohort Study from a Tertiary Trauma Centre

“…In our population, we had no delayed bleeding or differences in those on AT, even in those onclopidogrel, even if predisposed to it [ 27 ]. Of the five patients on AC with active bleeding, 3/5 were on warfarin.…”