The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury

Abstract

Therapeutic study, level IV.

Premorbid Use of Clopidogrel Portends Worse Outcomes in Patients Treated Surgically for Intracranial Hemorrhage

“…It has been suggested that an increase of 1% -2% of ICH rates can negate the benefits of antithrombotic therapy [11]. It should be noted that while the mortality of our study is disproportionately higher to what has been described in the literature [29] [30], this is the first paper, to our knowledge, that assesses the adverse effects of APAC use on patients presenting with surgically-treated intracranial hemorrhage.…”

“…However, the premorbid use of APACs has proven to be a difficult challenge in the presence of a neurosurgical emergency. They pose a risk factor for intracranial hemorrhage [1] and have been associated with poor prognoses in the settings of both spontaneous as well as trauma-related hemorrhage [6]- [10]. With respect to spontaneous hemorrhage, antithrombotic therapy is associated with 7000 of the 60,000 (12%) intracerebral hemorrhages (ICH) that occur annually in the United States (which represents approximately 1% of incidental strokes) [11].…”

“…However, the initiation of surgical evacuation also involves consideration of the natural history of intracranial hemorrhage, and an understanding of the patient's overall prognosis. Regarding ICH, recent investigations have addressed issues such as risk for hematoma expansion [13] [18]- [20], outcomes of intracranial hemorrhage in patients taking APACs [6]- [10] and differences in said outcomes between the various types of antithrombotics [10] [21]- [25]. These studies were performed primarily with regard to stroke, emergent care and care in a trauma setting, not to neurosurgical intervention.…”

“…With respect to spontaneous hemorrhage, antithrombotic therapy is associated with 7000 of the 60,000 (12%) intracerebral hemorrhages (ICH) that occur annually in the United States (which represents approximately 1% of incidental strokes) [11]. In the setting of trauma, APACs contribute to both the incidence as well as the severity of accompanying intracranial hemorrhage [10] [12]- [14]. Warfarin use may double the attendant risk of ICH.…”

Targeting coagulation factor XII as a novel therapeutic option in brain trauma

“…In clinical TBI, intracerebral vessel occlusion with subsequent ischemia worsens the outcome 8, 9, 11, 12. However, the potential use of conventional anticoagulants in patients with TBI is met with controversy, due to the increased risk of intracerebral hemorrhage 13, 14, 15, 16, 17, 18. Previous studies from our laboratory have shown that both genetic deficiency and pharmacological inhibition of the coagulation factor XII (FXII), a protease that initiates the activation of the intrinsic coagulation cascade, protect mice from ischemic stroke without increasing bleeding tendencies 19, 20.…”