Are oral anticoagulants a risk factor for mild traumatic brain injury progression? A single-center experience focused on of direct oral anticoagulants and vitamin K antagonists.
Aspirin
Direct oral anticoagulants
Mild traumatic brain injury
Oral anticoagulants
VKA
Journal
Acta neurochirurgica
ISSN: 0942-0940
Titre abrégé: Acta Neurochir (Wien)
Pays: Austria
ID NLM: 0151000
Informations de publication
Date de publication:
01 2022
01 2022
Historique:
received:
23
06
2021
accepted:
08
11
2021
pubmed:
2
12
2021
medline:
27
1
2022
entrez:
1
12
2021
Statut:
ppublish
Résumé
Mild traumatic brain injury (TBI) in anticoagulated patients is a common challenge for emergency departments because of lack of appropriate epidemiological data and huge management variability for those under oral anticoagulation therapy. Given the discrepancies between guidelines, the aim of the present study was to quantify the association between oral anticoagulant therapy (either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC)) and the post-traumatic intracranial hemorrhage worsening compared to admission CT scan. We included all consecutive records of patients admitted to our emergency department for mild TBI as chief complaint and with a positive admission CT scan. After statistical univariate comparison, cause-specific hazard ratio (HR) and 95% confidence interval (CI) were determined with the use of Cox proportional hazard model. In the study period, 4667 patients had a CT scan for mild TBI; 439 (9.4%) were found to have intracranial hemorrhage. Among these patients, 299 (68.1%) were prescribed observation and control CT: 46 (15.38%) were on anticoagulant therapy, 23 (50%) on VKA, and 23 (50%) on DOAC. In multivariate analysis, only oral anticoagulation therapy was significantly associated to an increased risk of intracranial hemorrhage progression (HR 2.58; 95% CI 1.411-4.703; p = .002 and HR 1.9; 95% CI 1.004-3.735; p = .0048 for VKA and DOAC, respectively). Surgery was due to isolated subdural hematoma in 87.5% of cases, to subdural hematoma associated with intraparenchymal hemorrhage in 9.38% and to intraparenchymal hemorrhage only in 3.12%; 13 cases (4.35%) deceased in intensive care unit. In our series, anticoagulation was associated to a significant increase in intracranial progression, leaving the question open as to what this implies in current clinical practice; subdural hematoma was the major finding associated to evolution and surgery. Against this background, further studies are needed to clarify patients' management and DOAC safety profile compared to VKA in mild TBI.
Sections du résumé
BACKGROUND
Mild traumatic brain injury (TBI) in anticoagulated patients is a common challenge for emergency departments because of lack of appropriate epidemiological data and huge management variability for those under oral anticoagulation therapy. Given the discrepancies between guidelines, the aim of the present study was to quantify the association between oral anticoagulant therapy (either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC)) and the post-traumatic intracranial hemorrhage worsening compared to admission CT scan.
METHODS
We included all consecutive records of patients admitted to our emergency department for mild TBI as chief complaint and with a positive admission CT scan. After statistical univariate comparison, cause-specific hazard ratio (HR) and 95% confidence interval (CI) were determined with the use of Cox proportional hazard model.
RESULTS
In the study period, 4667 patients had a CT scan for mild TBI; 439 (9.4%) were found to have intracranial hemorrhage. Among these patients, 299 (68.1%) were prescribed observation and control CT: 46 (15.38%) were on anticoagulant therapy, 23 (50%) on VKA, and 23 (50%) on DOAC. In multivariate analysis, only oral anticoagulation therapy was significantly associated to an increased risk of intracranial hemorrhage progression (HR 2.58; 95% CI 1.411-4.703; p = .002 and HR 1.9; 95% CI 1.004-3.735; p = .0048 for VKA and DOAC, respectively). Surgery was due to isolated subdural hematoma in 87.5% of cases, to subdural hematoma associated with intraparenchymal hemorrhage in 9.38% and to intraparenchymal hemorrhage only in 3.12%; 13 cases (4.35%) deceased in intensive care unit.
CONCLUSIONS
In our series, anticoagulation was associated to a significant increase in intracranial progression, leaving the question open as to what this implies in current clinical practice; subdural hematoma was the major finding associated to evolution and surgery. Against this background, further studies are needed to clarify patients' management and DOAC safety profile compared to VKA in mild TBI.
Identifiants
pubmed: 34850288
doi: 10.1007/s00701-021-05066-w
pii: 10.1007/s00701-021-05066-w
doi:
Substances chimiques
Anticoagulants
0
Vitamin K
12001-79-5
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
97-105Informations de copyright
© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.
Références
2019 surveillance of head injury: assessment and early management (NICE guideline CG176). National Institute for Health and Care Excellence (UK), London; September 5, 2019
Bittencourt-Villalpando M, van der Horn HJ, Maurits NM, van der Naalt J (2020) Disentangling the effects of age and mild traumatic brain injury on brain network connectivity: a resting state fMRI study [published online ahead of print, 2020 Dec 22]. Neuroimage Clin. 29:102534. https://doi.org/10.1016/j.nicl.2020.102534
doi: 10.1016/j.nicl.2020.102534
pubmed: 33360020
pmcid: 7770973
Brewer ES, Reznikov B, Liberman RF et al (2011) Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J Trauma 70(1):E1–E5. https://doi.org/10.1097/TA.0b013e3181e5e286
doi: 10.1097/TA.0b013e3181e5e286
pubmed: 20693913
Draper K, Schönberger M (2008) Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status. J Int Neuropsychol Soc 14(2):233–242. https://doi.org/10.1017/S1355617708080272
doi: 10.1017/S1355617708080272
pubmed: 18282321
Fiorelli EM, Bozzano V, Bonzi M et al (2020) Incremental risk of intracranial hemorrhage after mild traumatic brain injury in patients on antiplatelet therapy: systematic review and meta-analysis. J Emerg Med 59(6):843–855. https://doi.org/10.1016/j.jemermed.2020.07.036
doi: 10.1016/j.jemermed.2020.07.036
pubmed: 33008665
Grandhi R, Harrison G, Voronovich Z et al (2015) Preinjury warfarin, but not antipatelet medications, increases mortality in elderly traumatic brain injury patients. J trauma Acute Care Surg 78:614–621
doi: 10.1097/TA.0000000000000542
Hecht JP, LaDuke ZJ, Cain-Nielsen AH, Hemmila MR, Wahl WL (2020) Effect of Preinjury oral anticoagulants on outcomes following traumatic brain injury from falls in older adults. Pharmacotherapy 40(7):604–613. https://doi.org/10.1002/phar.2435
doi: 10.1002/phar.2435
pubmed: 32515829
Hu TT, Yan L, Yan PF, Wang X, Yue GF (2016 Jan) Assessment of the ABC/2 method of epidural hematoma volume measurement as compared to computer-assisted planimetric analysis. Biol Res Nurs 18(1):5–11. https://doi.org/10.1177/1099800415577634 (Epub 2015 Mar 23 PMID: 25802386)
doi: 10.1177/1099800415577634
pubmed: 25802386
Huttner HB, Steiner T, Hartmann M et al (2006) Comparison of ABC/2 estimation technique to computer-assisted planimetric analysis in warfarin-related intracerebral parenchymal hemorrhage. Stroke 37(2):404–408. https://doi.org/10.1161/01.STR.0000198806.67472.5c
doi: 10.1161/01.STR.0000198806.67472.5c
pubmed: 16373654
Kothari RU, Brott T, Broderick JP et al (1996) The ABCs of measuring intracerebral hemorrhage volumes. Stroke 27(8):1304–1305. https://doi.org/10.1161/01.str.27.8.1304
doi: 10.1161/01.str.27.8.1304
pubmed: 8711791
Marshall S, Bayley M, McCullagh S et al (2015) Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms. Brain Inj 29(6):688–700. https://doi.org/10.3109/02699052.2015.1004755
doi: 10.3109/02699052.2015.1004755
pubmed: 25871303
Peeters W, van den Brande R, Polinder S et al (2015) Epidemiology of traumatic brain injury in Europe. Acta Neurochir (Wien) 157(10):1683–1696. https://doi.org/10.1007/s00701-015-2512-7
doi: 10.1007/s00701-015-2512-7
Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS (2007) Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database. J Trauma 63(3):519–524. https://doi.org/10.1097/TA.0b013e31812e519b
doi: 10.1097/TA.0b013e31812e519b
pubmed: 18073595
Prexl O, Bruckbauer M, Voelckel W, Grottke O, Ponschab M, Maegele M, Schöchl H (2018 Mar 27) The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old. Scand J Trauma Resusc Emerg Med 26(1):20. https://doi.org/10.1186/s13049-018-0487-0.PMID:29580268;PMCID:PMC5870487
doi: 10.1186/s13049-018-0487-0.PMID:29580268;PMCID:PMC5870487
pubmed: 29580268
pmcid: 5870487
Silverberg ND, Iaccarino MA, Panenka WJ et al (2020) Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines. Arch Phys Med Rehabil 101(2):382–393. https://doi.org/10.1016/j.apmr.2019.10.179
doi: 10.1016/j.apmr.2019.10.179
pubmed: 31654620
Stiell IG, Wells GA, Vandemheen K et al (2001) The Canadian CT Head Rule for patients with minor head injury. Lancet 357(9266):1391–1396. https://doi.org/10.1016/s0140-6736(00)04561-x
doi: 10.1016/s0140-6736(00)04561-x
pubmed: 11356436
Stippler Nagesh M, Patel KR, Mishra A, Yeole U, Prabhuraj AR, Shukla D (2019) Role of repeat CT in mild to moderate head injury: an institutional study. Neurosurg Focus. 1;47(5):E2. https://doi.org/10.3171/2019.8.FOCUS19527
doi: 10.3171/2019.8.FOCUS19527
Trattamento del Trauma Cranico minore e severo - Linee guida nazionali di riferimento (Italian Consensus on MTBI treatment - SINCH)
Trevisi G, Scerrati A, Peppucci E, DeWaure C, Anile C, Mangiola A (2018) What is the best timing of repeated CT scan in mild head trauma with an initially positive CT scan? World Neurosurg 118:e316–e322. https://doi.org/10.1016/j.wneu.2018.06.185
doi: 10.1016/j.wneu.2018.06.185
pubmed: 29969739
Turcato G, Zannoni M, Zaboli A et al (2019) Direct oral anticoagulant treatment and mild traumatic brain injury: risk of early and delayed bleeding and the severity of injuries compared with vitamin K antagonists. J Emerg Med 57(6):817–824. https://doi.org/10.1016/j.jemermed.2019.09.007
doi: 10.1016/j.jemermed.2019.09.007
pubmed: 31648805
Van Ornam J, Pruitt P, Borczuk P (2019) Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage. Am J Emerg Med 37(9):1694–1698. https://doi.org/10.1016/j.ajem.2018.12.012
doi: 10.1016/j.ajem.2018.12.012
pubmed: 30559018
Vos PE, Alekseenko Y, Battistin L et al (2012) Mild traumatic brain injury. Eur J Neurol 19(2):191–198. https://doi.org/10.1111/j.1468-1331.2011.03581.x
doi: 10.1111/j.1468-1331.2011.03581.x
pubmed: 22260187
Vos PE, Battistin L, Birbamer G et al (2002) EFNS guideline on mild traumatic brain injury: report of an EFNS task force. Eur J Neurol 9(3):207–219. https://doi.org/10.1046/j.1468-1331.2002.00407.x
doi: 10.1046/j.1468-1331.2002.00407.x
pubmed: 11985628
Won SY, Zagorcic A, Dubinski D, et al. Excellent accuracy of ABC/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. PLoS One. 2018;13(6):e0199809. Published 2018 Jun 26. https://doi.org/10.1371/journal.pone.0199809