Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma

Chenoweth, James A.; Gaona, Samuel D.; Faul, Margaret M.; Holmes, James F.; Nishijima, Daniel K.

doi:10.1001/jamasurg.2017.6159

Cited by 62 publications

(54 citation statements)

References 18 publications

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“…Our result of the highest ICH figure being in VKA patients agrees with many studies in the literature [ 9 , 10 , 17 , 33 , 40 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ].…”

Section: Discussionsupporting

confidence: 93%

“…Minor head injury is defined as a patient with a history of loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 13–15 [ 1 , 2 ]. Anticoagulant medications are commonly used for a variety of indications [ 3 , 4 , 5 , 6 , 7 , 8 , 9 ], and it is widely believed that preinjury use of these medications increases the risk of traumatic intracranial injury and worsens clinical outcomes after blunt head trauma [ 10 , 11 , 12 , 13 ]. This belief is based largely on biological plausibility and retrospective cohort studies [ 14 , 15 , 16 , 17 ].…”

Section: Introductionmentioning

confidence: 99%

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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

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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.

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“…Our result of the highest ICH figure being in VKA patients agrees with many studies in the literature [ 9 , 10 , 17 , 33 , 40 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ].…”

Section: Discussionsupporting

confidence: 93%

Section: Introductionmentioning

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

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“…The results of our study, with only one clinically significant case of delayed intracranial hemorrhage (0.3% in the repeat CT group, 0.1% in total), support other investigations which concluded that a routine repeat CT is not necessary for patients with antithrombotic therapy, due to the low clinical significance of most detected DIH [27,28,29,30,31,32]. The single case of a clinically significant DIH in our study showed an altered neurological status and would therefore have received an additional CT during the observation period regardless of clinical protocol for routine repeat CT.…”

Section: Discussionsupporting

confidence: 88%

“…Despite all guidelines, it is still necessary to make decisions based on risk stratification while considering the consequences for the individual patient. Chenoweth et al [28] found a 0.3% rate of DIH in their prospective study including patients with and without ATT, and concluded that “this (the low risk of DIH and fact that they can occur later than 24 h) highlights the importance of clinical judgment regarding the severity of trauma, additional injuries, and ability to monitor the patient for deterioration when making decisions about admission for older patients after blunt head trauma.”…”

Section: Discussionmentioning

confidence: 99%

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

Antoni

Schwendenwein

Binder

et al. 2019

JCM

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Background: Delayed intracranial hemorrhage can occur up to several weeks after head trauma and was reported more frequently in patients with antithrombotic therapy. Due to the risk of delayed intracranial hemorrhage, some hospitals follow extensive observation and cranial computed tomography (CT) protocols for patients with head trauma, while others discharge asymptomatic patients after negative CT. Methods: We retrospectively analyzed data on patients with head trauma and antithrombotic therapy without pathologies on their initial CT. During the observation period, we followed a protocol of routine repeat CT before discharge for patients using vitamin K antagonists, clopidogrel or direct oral anticoagulants. Results: 793 patients fulfilled the inclusion criteria. Acetylsalicylic acid (ASA) was the most common antithrombotic therapy (46.4%), followed by vitamin K antagonists (VKA) (32.2%) and Clopidogrel (10.8%). We observed 11 delayed hemorrhages (1.2%) in total. The group of 390 patients receiving routine repeat CT showed nine delayed hemorrhages (2.3%). VKA were used in 6 of these 11 patients. One patient needed an urgent decompressive craniectomy while the other patients were discharged after an extended observation period. The patient requiring surgical intervention due to delayed hemorrhage showed neurological deterioration during the observation period. Conclusions: Routine repeat CT scans without neurological deterioration are not necessary if patients are observed in a clinical setting. Patients using ASA as single antithrombotic therapy do not require in-hospital observation after a negative CT scan.

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“…5 The reported risk of delayed ICH after head injury has varied in the literature from 0% to 4%. [10][11][12][13][14][15][16] Several clinical guidelines highlight the risk of traumatic delayed ICH in patients taking antiplatelet agents. [17][18][19] According to the 2014 National Institute of Health and Care Excellence guidelines on head injury, for patients on aspirin or clopidogrel, 'the reference standard should include CT head scan and a follow-up period of sufficient duration to capture delayed bleeding, for example, at 7 days and 1 month'.…”

Section: Introductionmentioning

confidence: 99%

Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries

Alter

Mazer

Solano

et al. 2020

Trauma Surg Acute Care Open

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BackgroundAntiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy.MethodsA retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals’ trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians’ discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome.ResultsOf 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate.ConclusionsPatients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients.Level of evidenceLevel III, prognostic.

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Incidence of Delayed Intracranial Hemorrhage in Older Patients After Blunt Head Trauma

Cited by 62 publications

References 18 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 Patients with Head Trauma and Antithrombotic Therapy

Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries

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