Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis

Abstract

BackgroundPatients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group.MethodsAn observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies.Results148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%).ConclusionsThe risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.

Modified Protocol to Enable the Study of Hemorrhage and Hematoma in a Traumatic Brain Injury Mouse Model

“…Hrr in the brain parenchyma following TBI could be a space-occupied mass and thus could induce the compressive pressure to local tissue followed by a reduction of blood flow and intracranial pressure (ICP) elevation. In addition, recent studies have shown that anticoagulant therapy, including warfarin, worsens the symptoms rapidly in patients with TBI due to side effects such as massive Hrr ( 7 ). Therefore, therapeutic management of Hrr or hematomas might be a key point in the treatment of TBI, which is a common procedure in clinics.…”

What's new in emergencies, trauma, and shock: Head Injury in anticoagulated patients – an enigma

“…There is sparse and conflicting evidence directing the outcomes and management of head injury in patients anticoagulated with DOAC. [ 2 ] DOAC have become the new standard anticoagulants replacing the Vitamin K antagonists (VKA) in clinical practice worldwide. Research on the outcomes of such patients of traumatic brain injury (TBI) becomes important to guide the management practices.…”

“…[ 3 ] The guidelines are based on the systematic reviews of the available literature, but we need to take the results of these systematic reviews with a pinch of salt because the studies they included were very heterogeneous in the nature of their study designs and inclusion and exclusion criteria. [ 2 ]…”

“…Based on the evidence available, a repeat CT is needed only in those patients having documented ICH in the initial CT or those with normal initial CT who deteriorate during observation or after discharge or those who cannot be examined neurologically due to intubation, sedation, or dementia. [ 2 3 4 ]…”

“…Anticoagulated patients with minor head injury are mostly elders who suffer a ground-level fall leading to a minor head injury. [ 2 ] They make the bulk of emergency department (ED) referrals for assessment and observation. Physicians in ED should be clear in their approach to such patients.…”