Risk of Intracranial Hemorrhage in Ground‐level Fall With Antiplatelet or Anticoagulant Agents

Ganetsky, Michael; Lopez, Gregory J.; Coreanu, Tara; Novack, Victor; Horng, Steven; Shapiro, Nathan I.; Bauer, Kenneth A.

doi:10.1111/acem.13217

Cited by 54 publications

(52 citation statements)

References 25 publications

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“…Although anticoagulation is often cited as a major risk factor for traumatic intracranial bleeding, we did not confirm that association. In this regard, our findings are similar to those published by Nishijima et al and Ganetsky et al and question the logic of ordering an ED head CT for older adults who have fallen, solely on the basis that they are on an anticoagulant.…”

Section: Discussionsupporting

confidence: 91%

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study

Wit

Parpia

Varner

et al. 2020

J American Geriatrics Society

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OBJECTIVES: Emergency department (ED) visits among older adults are frequently instigated by a fall at home. Some of these patients develop intracranial bleeding. The aim of this study was to identify the incidence of intracranial bleeding and the associated clinical features in older adults who present to the ED after falling. DESIGN: Prospective cohort study. SETTING: Three Canadian EDs. PARTICIPANTS: A total of 2 176 patients age 65 years or older who presented to the ED with a fall were assessed, and 1753 were included. Inclusion criteria were a fall on level ground, off a bed, chair, or toilet, or from one or two steps within 48 hours. MEASUREMENTS: Emergency physicians recorded predefined clinical findings on initial assessment. The primary outcome was intracranial bleeding, diagnosed either by computed tomography at the index visit or within 42 days. Associations between baseline clinical findings and the presence of intracranial bleeding were assessed with multivariable logistic regression. RESULTS: A total of 1753 patients (median age = 82 y) were enrolled, of whom 39% were male, 35% were on antiplatelet therapy, and 25% were on an anticoagulant. The incidence of intracranial bleeding was 5.0% (95% confidence interval [CI] = 4.1-6.1). Overall, 76 patients were diagnosed at the index ED visit, and 12 were diagnosed during follow-up. Multivariable regression identified four clinical variables that were independently associated with intracranial bleeding: new abnormalities on neurologic examination (odds ratio [OR] = 4.4; 95% CI = 2.4-8.1), bruise or laceration on the head (OR = 4.3; 95% CI = 2.7-7.0), chronic kidney disease (OR = 2.4; 95% CI = 1.3-4.6), and reduced Glasgow Coma Scale from normal (OR = 1.9; 95% CI = 1.0-3.4). CONCLUSION: The incidence of intracranial bleeding in our study was 5.0%. We found significant associations between intracranial bleeding and four simple clinical variables. We did not find significant associations between intracranial bleeding and antiplatelet or anticoagulant use. J Am Geriatr Soc 68:970-976, 2020.

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Section: Discussionsupporting

confidence: 91%

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study

Wit

Parpia

Varner

et al. 2020

J American Geriatrics Society

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“…To date, specific recommendations are missing for low‐energy trauma in older patients such as ground‐level falls with or without anticoagulation or antiplatelet treatments and equivocal clinical signs of traumatic brain injury. Current studies on these particular patients are heterogeneous and bear some limitations, such as missing control group, small sample sizes, or lacking information about injury severity …”

mentioning

confidence: 99%

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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“…[6][7] However, some studies have not identified an increase in post fall ICH in this cohort and conclude that concerns regarding OAC agents are overstated. [8][9] Atrial fibrillation guidelines recommend anticoagulation for almost all older patients, 10-11 thus, physicians have a difficult choice: to provide OAC to minimize vascular risk while increasing the risk of ICH or vice versa. 2 Anticoagulation introduces complexity and cost to post-fall injury management.…”

Section: Discussionmentioning

confidence: 99%

Poster Presentations

2020

Emerg Medicine Australasia

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Risk of Intracranial Hemorrhage in Ground‐level Fall With Antiplatelet or Anticoagulant Agents

Cited by 54 publications

References 25 publications

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study

Clinical Predictors of Intracranial Bleeding in Older Adults Who Have Fallen: A Cohort Study

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

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