Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants

Turcato, Gianni; Zaboli, Arian; Zannoni, M; Ricci, Giorgio; Zorzi, Elisabetta; Ciccariello, Laura; Tenci, Andrea; Pfeifer, Norbert; Antonio, Miguel; Bonora, Antonio

doi:10.1016/j.ajem.2020.02.046

Cited by 10 publications

(5 citation statements)

References 25 publications

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“…Spinola et al, whose cohort included 402 patients, observed a higher incidence of intracranial haemorrhage in patients taking VKAs than those taking DOACs (10.2% vs 2.6%, p<0.01). 17,20,23 This was confirmed in the study by Cipriano et al (n = 206), in which the risk of ITH was significantly higher for patients treated with VKAs (15.7% vs 4.7%, RR 3.34, 95% CI 1.18-9.46, p<0.05). No difference was observed in delayed bleeding after an initial negative CT scan.…”

Section: Discussionmentioning

confidence: 55%

“…A previous study found that 7% of elderly patients receiving OAT presented a post-traumatic hemorrhagic complication, a statistic that can be compared with rates in other areas of minor trauma, such as mild traumatic brain injury, in which post-traumatic bleeding occurs in between 3% and 10% of cases. [17][18][19][20] This study was designed to focus attention on elderly patients treated with OAT who present in the ED mainly due to a chest trauma caused by an apparently non-severe dynamic injury (accidental fall, direct trauma). Along with mild traumatic brain injury, chest trauma appears to be a frequent consequence of falls in the elderly, and although the risk of complications does not appear high for either of these conditions, concomitant OAT complicates their management.…”

Section: Discussionmentioning

confidence: 99%

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Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

et al. 2021

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Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.

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Section: Discussionmentioning

confidence: 55%

Section: Discussionmentioning

confidence: 99%

Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

et al. 2021

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“…Recent evidence seems to suggest that the same clinical risk factors extensively studied in mTBI could be used in the first assessment of the subgroup of patients on OAT [33][34][35][36][37][38][39][40][41][42]. In a prospective study, Cipriano et al [33] found that PTA and trauma above the clavicles remain independent predictors for ICI in people on OAT.…”

Section: Clinical Decision Rulesmentioning

confidence: 99%

“…Some data [34][35][36], indeed, showed a lower risk of ICI in patients on DOAs compared to those on VKAs, justifying the introduction of specific management strategies. In two different analyses [36,37], Turcato et al reported that major dynamics, PTA, post-traumatic transitory loss of consciousness (TLOC), GCS score < 15, post-traumatic headache, and evidence of trauma above the clavicles were associated with a higher likelihood of ICI in patients on DOAs. The same group [38] conducted a decision tree analysis with the chi-square automatic interaction detection (CHAID) method, a statistical machine learning technique, to analyze the relative weight of clinical risk factors in predicting the risk of ICI in patients taking DOAs.…”

Section: Clinical Decision Rulesmentioning

confidence: 99%

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

Menditto,

Rossetti,

Sampaolesi

et al. 2024

JCM

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The best management of patients who suffer from traumatic brain injury (TBI) while on oral anticoagulants is one of the most disputed problems of emergency services. Indeed, guidelines, clinical decision rules, and observational studies addressing this topic are scarce and conflicting. Moreover, relevant issues such as the specific treatment (and even definition) of mild TBI, rate of delayed intracranial injury, indications for neurosurgery, and anticoagulant modulation are largely empiric. We reviewed the most recent evidence on these topics and explored other clinically relevant aspects, such as the promising role of dosing brain biomarkers, the strategies to assess the extent of anticoagulation, and the indications of reversals and tranexamic acid administration, in cases of mild TBI or as a bridge to neurosurgery. The appropriate timing of anticoagulant resumption was also discussed. Finally, we obtained an insight into the economic burden of TBI in patients on oral anticoagulants, and future directions on the management of this subpopulation of TBI patients were proposed. In this article, at the end of each section, a “take home message” is stated.

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“…Intracranial injuries are typically associated with some form of vascular disruption and resultant bleeding into the intracranial space, resulting in a myriad of neurological outcomes (8). The risk of intracranial bleeding could be increased by the use of anticoagulant medication (9). This risk is signi cant as the use of anticoagulant and antiplatelet medication is higher in older individuals as part of a trend towards higher life expectancies (10).…”

Section: Introductionmentioning

confidence: 99%

Outcomes in terms of morbidity and mortality among elderly head injury patients on pre-injury anticoagulation: A systematic review protocol

Ogbu

2022

Preprint

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Background: The global burden of traumatic brain injuries continues to remain grossly underestimated and is thought to cost about US$400 billion annually. Elderly individuals have the highest age-specific rates of TBIs and are more likely to take anticoagulant medication than other age groups and are therefore theoretically at a higher risk of morbidity and mortality following head injuries. However, the evidence for these worse outcomes is at best unclear, and this has a significant impact on decision-making in clinical settings, sometimes resulting in unnecessary delays to treatment.Methods: This protocol has been developed using the PRISMA-P guidelines. We will search the main clinical indexing databases (including PubMed/MEDLINE, EMBASE, Cochrane reviews, and ClinicalTrials.gov) for studies that evaluated outcomes in terms of morbidity and mortality among anticoagulated individuals aged over 65, to identify all English language studies published between the years 2000 and 2021. The identified studies will then be screened using pre-determined eligibility criteria detailed in the body of this work. Finally, two independent reviewers will screen, select, evaluate the included studies for quality, and extract data related to the use of anticoagulants in the elderly from all relevant sources. A logically sound analytic framework will then be employed to determine the impact of the use of anticoagulation on outcomes as outlined. Discussion: This study aims to identify the existing evidence for outcomes in this population, contribute to the current body of knowledge, and provide more explicit guidance for clinical practice. We envisage that the findings surrounding outcomes in the head-injured, anticoagulated elderly population will guide clinicians towards better decision-making in both the in-patient and out-patient setting and contribute to the development of clinical guidelines. Systematic review registration: This systematic review is registered on the PROSPERO database with registration number: CRD42021220974

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Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants

Cited by 10 publications

References 25 publications

Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

Safety and differences between direct oral anticoagulants and vitamin K antagonists in the risk of post-traumatic intrathoracic bleeding after rib fractures in elderly patients

Traumatic Brain Injury in Patients under Anticoagulant Therapy: Review of Management in Emergency Department

Outcomes in terms of morbidity and mortality among elderly head injury patients on pre-injury anticoagulation: A systematic review protocol

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