Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs

Cipriano, Alessandro; Park, Naria; Pecori, Alessio; Bionda, Alessandra; Bardini, Michele; Frassi, Francesca; Lami, Valentina; Leoli, Francesco; Manca, Maria Laura; Prato, Stefano Del; Santini, Massimo; Ghiadoni, Lorenzo

doi:10.1007/s11739-020-02576-w

Cited by 21 publications

(27 citation statements)

References 44 publications

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“…The present study's relatively low incidence of TICH in ACT-patients has been reported by several other studies in the past years [1,[15][16][17][18][19][20]. Even though one-third of the ACTpatients in the present study were on VKAs and not DOACs, the TICH-incidence did not differ significantly from the TICH-incidence in the cohort of patients with ground-level traumas not on ACT or APT.…”

Section: Discussionsupporting

confidence: 51%

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Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

Vedin

Forberg

Anefjäll

et al. 2022

Eur J Trauma Emerg Surg

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Background Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls. Methods This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included. Results The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13–2.60) and 1.08 (p = 0.73), (95% CI 0.70–1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02–2.49), p = 0.041). Conclusion This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

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Section: Discussionsupporting

confidence: 51%

“…The prevalence of TICH in patients with APT has been reported between 10 and 40% compared to 5 and 20% in ACT-patients. TICH seems to be lower in patients on direct-acting oral anticoagulants (DOACs) than in patients taking Vitamin-K Antagonists (VKAs) [1,[15][16][17][18][19][20].…”

Section: Introductionmentioning

confidence: 99%

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

Vedin

Forberg

Anefjäll

et al. 2022

Eur J Trauma Emerg Surg

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“…In the next future, the management of these patients could be based on clinical and trauma-related risk factors rather than anticoagulation therapy alone as proposed in some recent trials. 22,29,30…”

Section: Resultsmentioning

confidence: 99%

“…31 In a 6-year retrospective analysis, Riccardi et al found a significant increased risk of post-traumatic intracranial bleeding in patients with loss of consciousness, headache, vomiting, or neurological signs. 19 Post-traumatic amnesia, evidence of trauma above the clavicles, high blood glucose, high blood pressure at arrival to the ED, and low prothrombin activity were predictors for ICH in patients suffering mTBI while OAT in a recent study by Cipriano et al 30 In a retrospective observational study above patients taking DOACs, Turcato et al 29 found that major dynamics, post-traumatic loss of consciousness, post-traumatic amnesia, GCS<15, post-traumatic headache, and visible trauma above the clavicles were asso- o n l y ciated with a higher likelihood of ICH. Nishijima et al 21 recently conducted a prospective multicentric study where history of vomiting, evidence of trauma above the clavicles, or an abnormal GCS score are more predictive of traumatic ICH than anticoagulant or antiplatelet use; mechanism of injury other than ground-fall and a history of loss of consciousness or amnesia were independent risk factors for the incidence of traumatic ICH on initial cranial CT scan as well.…”

Section: Which Are Possible Predictors Of Ich After Mtbi?mentioning

confidence: 96%

“…Several studies demonstrated a safer profile of DOACs both in the setting of spontaneous and traumatic ICH (Table 3). 27,29,30,[32][33][34][35][36][37][38][39][40] A systematic review by Fuller et al of seven observational studies estimates that the prevalence of adverse outcomes (death, intracranial hematoma, or neurosurgery) after mTBI in patients taking DOACs ranged from 0.0% to 8.3%. 27 This value is almost half of the rate of traumatic ICH above patients in OAT with VKAs, as documented in several other studies.…”

Section: Are Doacs Safer Than Vkas?mentioning

confidence: 99%

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The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department

et al. 2022

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The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice.

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Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation—a single-center experience

Niklasson,

Svensson,

André

et al. 2024

Eur J Trauma Emerg Surg

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Purpose Traumatic brain injury is the main reason for the emergency department visit of up to 3% of the patients and a major worldwide cause for morbidity and mortality. Current emergency management guidelines recommend close attention to patients taking oral anticoagulation but not patients on antiplatelet therapy. Recent studies have begun to challenge this. The aim of this study was to determine the impact of antiplatelet therapy and oral anticoagulation on traumatic intracranial hemorrhage. Methods Medical records of adult patients triaged with “head injury” as the main reason for emergency care were retrospectively reviewed from January 1, 2017, to December 31, 2017, and January 1, 2020, to December 31, 2021. Patients ≥ 18 years with head trauma were included. Odds ratio was calculated, and multiple logistic regression was performed. Results A total of 4850 patients with a median age of 70 years were included. Traumatic intracranial hemorrhage was found in 6.2% of the patients. The risk ratio for traumatic intracranial hemorrhage in patients on antiplatelet therapy was 2.25 (p < 0.001, 95% confidence interval 1.73–2.94) and 1.38 (p = 0.002, 95% confidence interval 1.05–1.84) in patients on oral anticoagulation compared to patients without mediations that affect coagulation. In binary multiple regression, antiplatelet therapy was associated with intracranial hemorrhage, but oral anticoagulation was not. Conclusion This study shows that antiplatelet therapy is associated with a higher risk of traumatic intracranial hemorrhage compared to oral anticoagulation. Antiplatelet therapy should be given equal or greater consideration in the guidelines compared to anticoagulation therapy. Further studies on antiplatelet subtypes within the context of head trauma are recommended to improve the guidelines’ diagnostic accuracy.

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Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs

Cited by 21 publications

References 44 publications

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department

Higher risk of traumatic intracranial hemorrhage with antiplatelet therapy compared to oral anticoagulation—a single-center experience

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