Intracranial bleeding risk after minor traumatic brain injury in patients on antithrombotic drugs

Galliazzo, Silvia; Bianchi, Matteo; Virano, Alexandra; Trucchi, Alberto; Donadini, Marco Paolo; Dentali, Francesco; Bertù, Lorenza; Grandi, Andrea; Ageno, Walter

doi:10.1016/j.thromres.2018.12.015

Cited by 29 publications

(38 citation statements)

References 22 publications

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“…Prior studies and meta‐analyses related to this topic demonstrated an association between tICHs and anticoagulation or antiplatelet agents in patients with head trauma . However, more recent studies did not demonstrate such an association, which is in line with our findings. However, due to different inclusion criteria of the studies, direct comparisons are difficult.…”

Section: Discussionmentioning

confidence: 53%

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

Lampart

Kuster

Nickel

et al. 2020

J American Geriatrics Society

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BACKGROUND/OBJECTIVES: To determine the prevalence and severity of traumatic intracranial hemorrhage (tICH) in a large cohort of older adults presenting with lowenergy falls and the association with anticoagulation or antiplatelet medication. DESIGN: Bicentric retrospective cohort analysis. SETTING: Two level 1 trauma centers in Switzerland and Germany. PARTICIPANTS: Consecutive sample of older adults (aged ≥65 y) presenting to the emergency department (ED) over a 1-year period with low-energy falls who received cranial computed tomography (cCT) within 48 hours of ED presentation. MEASUREMENTS: The prevalence and severity of tICHs was assessed and the outcomes (in-hospital mortality, admission to intensive care unit [ICU], or neurosurgical intervention) were specified. We used multivariate regression models to measure the association between anticoagulation/antiplatelet therapy and the risk for tICH after adjustment for known predictors. RESULTS: The overall prevalence for tICH detected by cCT was 176 of 2567 (6.9%). Neurosurgical intervention was performed in 15 of 176 (8.5%) patients with tICH, 28 of 176 (15.9%) patients were admitted to the ICU, and 14 of 176 (8.0%) died in the hospital. CT-detected skull fracture and signs of injury above the clavicles were the strongest predictors for the presence of tICH (odds ratio [OR] = 4.28; 95% confidence interval [CI] = 2.79-6.51; OR = 1.88; 95% CI = 1.3-2.73, respectively). Among 2567 included patients, 1424 (55%) were on anticoagulation/antiplatelet therapy. Multivariate regression models showed no differences for the risk of tICH (OR = 1.05; 95% CI = .76-1.47; P = .76) or association with the head-specific Injury Severity Scale (incident rate ratio = 1.08; 95% CI = .97-1.19; P = .15) with or without anticoagulation/antiplatelet therapy. CONCLUSION: Medication with anticoagulants or antiplatelet agents was not associated with higher prevalence and severity of tICH in older patients with low-energy falls undergoing cCT examination. In addition to cCT-detected skull fractures, visible injuries above the clavicles were the strongest clinical predictors for tICH. Our findings merit prospective validation. J Am Geriatr Soc 68:977-982, 2020.

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Section: Discussionmentioning

confidence: 53%

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

Lampart

Kuster

Nickel

et al. 2020

J American Geriatrics Society

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“…Several studies have reported no increased risk for bleeding, mortality or neurosurgical interventions with antiplatelet medications. [25][26][27][28] However, a meta-analysis with over 20 000 patients showed a pooled OR of 1.87 (95% CI 1.27 to 2.74) with increased odds of ICH for patients on all antiplatelet therapy, although not for patients on aspirin alone. 5 This conflicting evidence highlights the need for more prospective trials on the effects of antiplatelet medications on ICH and the risk to patients.…”

Section: Discussionmentioning

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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“…The studies were published between 2009 and 2019; one study was performed in Italy [ 17 ], eleven studies in the USA [ 11 , 18 – 27 ], three studies in Austria [ 28 – 30 ] and one in Australia [ 31 ]. Four studies were multicentric [ 20 , 24 , 27 , 31 ], twelve had a retrospective design [ 11 , 17 – 19 , 22 , 23 , 25 – 28 , 30 , 31 ] and four had a prospective design [ 20 , 21 , 24 , 29 ]. Two studies were described in abstracts only [ 18 , 31 ], and the remaining 14 studies were published as full-text articles.…”

Section: Resultsmentioning

confidence: 99%

“…Four studies enrolled only patients ≥ 65 years old [ 19 , 23 , 26 , 29 ], one enrolled patients ≥ 60 years old [ 28 ], and one enrolled patients ≥ 55 years old [ 20 ]. The others included adult patients without age restriction [ 11 , 17 , 18 , 21 , 24 , 25 , 30 ] or did not specify any age restrictions in the inclusion or exclusion criteria [ 22 , 27 , 31 ].…”

Section: Resultsmentioning

confidence: 99%

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

Colombo

Bonzi

Fiorelli

et al. 2021

Scand J Trauma Resusc Emerg Med

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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.

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Intracranial bleeding risk after minor traumatic brain injury in patients on antithrombotic drugs

Cited by 29 publications

References 22 publications

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

Prevalence and Severity of Traumatic Intracranial Hemorrhage in Older Adults with Low‐Energy Falls

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

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

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