Selected Topics: Neurological Emergencies
Delayed Intracranial Hemorrhage in Anticoagulated Geriatric Patients After Ground Level Falls

https://doi.org/10.1016/j.jemermed.2019.09.011Get rights and content

Abstract

Background

The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined.

Objective

We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs.

Methods

A retrospective review of our trauma registry was performed on geriatric patients (age older than 64 years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March 2018.

Results

Seventy-seven patients met inclusion criteria. The mean age was 80 ± 7.7 years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p = 0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3–15] vs. 5 [1–9]; p = 0.030) and Abbreviated Injury Scale–Head score (median [interquartile range]: 1 [0–3] vs. 1 [0–2]; p = 0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ = –0.064; p = 0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs.

Conclusions

A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted.

Introduction

The leading cause of death in trauma patients is traumatic brain injury (TBI) (1). According to the Centers for Disease Control and Prevention, there are about 2.5 million TBI-related emergency department visits annually (1). Falls account for nearly half of all TBI-related emergency department visits and 81% of TBI-related visits in adults aged 65 years and older (2).

Patients on anticoagulation and antiplatelet medications are at increased risk for intracranial hemorrhage (ICH) after blunt head trauma and have worse outcomes (1,3,4). During the last decade, prescribers have rapidly shifted from warfarin to novel oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (A-fib). Zhu et al. found patients initiating anticoagulation for nonvalvular A-fib increased from 8.1% at the end of 2010 to nearly 80% in the beginning of 2017 (5). NOACs have been preferred over warfarin due to their superior safety profile and the ability to dose patients without trending coagulation studies (4, 5, 6).

Delayed ICH is defined as “blunt head injury with initial normal cranial computed topographic (CT) scan followed by an interval development of traumatic ICH on repeat imaging” (1,7). The risk for delayed ICH in a trauma patient on warfarin is estimated to be between 0.6% and 6%, and nearly all traumatic ICHs in these patients are captured on initial cranial (CT) scan. Therefore, routine repeat CT is not considered necessary in a patient taking warfarin that has experienced blunt head trauma (1,3,7, 8, 9).

Scant literature is currently available regarding the prevalence and risk for traumatic ICH and delayed ICH in patients taking NOACs. Chenoweth et al. reported that dabigatran has a similar risk of ICH after minor head trauma compared to warfarin (4.3%), but this study was limited by its small number of patients (n = 33) and was a single-center retrospective analysis (6). However, Beynon et al. reported that rivaroxaban had a higher mortality rate and worsened ICH in patients with minor TBI compared to no antithrombotics or antiplatelet agents (10).

As the U.S. population grows and the number of geriatric patients prescribed NOACs rises, it is imperative to characterize the risk for immediate and delayed ICH to guide physicians in managing these patients. Following institutional analysis of our trauma outcomes, we identified several cases of delayed ICH among NOAC patients and, as a result, instituted repeat head CT scans in this population. The aim of this study is to determine the incidence of delayed ICH and the need for repeat imaging for geriatric trauma patients on NOACs.

Section snippets

Materials and Methods

Institutional Review Board approval of this study was obtained. A retrospective review was performed using the trauma registry at our academic level I trauma center. Inclusion criteria were geriatric patients (aged older than 64 years) who were initially evaluated at our institution, had a fall from standing height or less, and were on anticoagulation (warfarin or NOACs) from April 2017 to March 2018. Chart review was used to characterize head CT scan results of the initial and repeat head CT

Results

Between April 2017 to March 2018, 77 patients met inclusion criteria. Overall, patient characteristics were similar between those taking warfarin vs. NOACs (Table 1). The average age of both groups was approximately 80 years and there were equal numbers of males and females in each group. Presentation Glasgow Coma Scale and discharge Glasgow Outcome Scale scores were also similar between the two groups. Patients taking warfarin had a significantly higher Injury Severity Score (median

Discussion

Prescribers have favored NOACs over warfarin since their approval by the U.S. Food and Drug Administration (4). The proportion of patients taking NOACs has increased during the last decade and the geriatric population makes up a large portion of patients that require anticoagulation (4). Among the geriatric population, falls have surpassed motor vehicle collisions as the predominant mechanism of trauma activation and are the leading cause of TBI (2). As the mean age of trauma patients increases

Conclusions

The risk of traumatic ICH in geriatric patients taking NOACs compared to warfarin was previously unknown. In our study, the risk of traumatic ICH in patients on NOACs was 20.8%, with a 14% delayed rate of bleed. LOC is not a reliable historical marker to rule out TBI. Based on our findings, our institution has introduced a protocol for repeating a head CT in geriatric trauma patients taking NOACs in order to evaluate for delayed presentation of ICH. Due to the potential clinical ramifications

References (13)

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Cited by (14)

  • Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use

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    Higher rates of dICH in patients on warfarin compared to those on DOACs were reported in many smaller observational studies.31-33 Conversely, among traumatic brain injury patients on preinjury anticoagulants who had a repeat brain scan following an initial negative scan, Cocca et al34 found a 14% incidence of dICH for those on DOACs compared to 0% on warfarin. Similarly, Battle et al35 and Mann et al15 reported an increased incidence of dICH in patients on DOAC therapy compared to warfarin.

  • Risk of delayed intracranial haemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury

    2022, American Journal of Emergency Medicine
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    In the study performed by Mourad et al., patients presenting after 12 h following trauma and after an initial negative CT scan were excluded from a second CT scan, suggesting that the presumed risk of delayed ICH may be zero after this time [10]. The time frame in which the risk of delayed ICH should be ruled out with confidence is not universal, and some authors previously suggested considering repeat CT even beyond 24 h after trauma for patients taking VKAs [14,22,23]. Unfortunately, both the current study and the study by Mourad et al. do not consider the time interval between trauma and the last intake of DOACs, limiting the possibility of correlating this information with the risk of delayed ICH [10].

  • Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective

    2021, Surgery (United States)
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    In addition, there is a lack of consistency among the guidelines on whether the type of outpatient antithrombotic therapy a patient is on influences the need for a repeat CT. Studies report conflicting evidence regarding the risk of DICH for patients on direct oral anticoagulants (DOACs) and whether the risk of DICH is significant enough to warrant repeat head CTs17,18 This is important as DOACs are increasingly replacing warfarin therapy.8 Multiple studies have reported the risks of DICH to be higher in patients on warfarin than on DOACs, stating that routine repeat head CT remain an important part of the management of TBI in this patient population.19–21

  • Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis

    2021, Journal of the American College of Surgeons
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    Studies comparing the risk of delayed ICH in patients taking DOAC vs warfarin have reported inconsistent results. A recent study by Cocca and colleagues,18 which included 44 patients on DOACs, found that 14% developed a delayed ICH, while none of 33 patients anticoagulated with warfarin suffered delayed ICH. A higher rate of delayed ICH in DOAC patients was also seen in several smaller studies.13,19,20

  • Delayed Intracranial Hemorrhage After Blunt Head Injury With Direct Oral Anticoagulants

    2021, Journal of Surgical Research
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    The high negative predictive value of CT makes it an invaluable tool to rule out intracranial hemorrhage at the time of presentation7; however, previous studies have suggested that patients taking either anticoagulant or antiplatelet agents may be at persistent risk of “delayed intracranial hemorrhage (d-ICH).” Per findings of ICH on follow up head CT (obtained between 6 hours and 7 d after the initial imaging5,8-12), the risk of d-ICH among patients who fell while taking warfarin was reported between 0.6% and 6.0%. Subsequent guidelines recommended admission for 24-h observation and withholding of warfarin in posthead injury patients (with or without repeating the CT); even if the initial CT was negative for ICH.10

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This abstract was presented as a late-breaking research topic at the American Association of Neurologic Surgeons meeting in April 2019 in San Diego, CA.

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