Brief ReportRisk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use☆
Introduction
With an aging population, older adults with preinjury anticoagulant or antiplatelet use represent an increasing proportion of patients with head injury evaluated in the emergency department [1]. These patients often have relatively minor mechanisms of injury and benign clinical presentations yet have significant intracranial injuries [2]. In the presence of traumatic intracranial hemorrhage (tICH), the effects of the anticoagulant or antiplatelet medications increase the risk for hemorrhage progression and bleeding complications during neurosurgery [3], [4], [5]. Prior studies demonstrate an increased risk for in-hospital mortality in these patients with tICH compared with patients without preinjury anticoagulant or antiplatelet use [6], [7], [8]. However, the impact of preinjury anticoagulant or antiplatelet use on long-term functional outcomes has not been evaluated.
The objective of this study was to compare long-term functional outcomes in older adults with mild tICH and preinjury warfarin or clopidogrel use to a similar cohort of patients without preinjury use of these medications. We hypothesized that the preinjury warfarin or clopidogrel cohort will have a significantly higher proportion of unfavorable functional outcome at 6 months compared with the control cohort.
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Study design and setting
This was a retrospective, registry study conducted at a Level 1 trauma center. The study was approved by the Institutional Review Board at the study site.
Selection of participants
The population included older adults (55 years and older) with tICH (defined as intracranial hemorrhage or contusion on cranial computed tomography [CT]), mild TBI (Glasgow Coma Scale [GCS] score 13-15), and an isolated head injury (Abbreviated Injury Score [AIS] < 3 in all nonhead body regions). Patients meeting these inclusion criteria were
Results
A total of 153 patients 55 years and older and with tICH were identified in the TBI database from April 2009 to July 2010. Seventy-seven patients met the inclusion criteria: 27 patients in the preinjury warfarin or clopidogrel cohort and 50 patients in the control cohort (Fig.). The primary indication for warfarin use was atrial fibrillation (11/15 patients, 73%), and the primary indication for clopidogrel use was coronary artery disease (10/12 patients, 83%). The most common cranial CT
Discussion
The results of our study suggest that older adults with preinjury warfarin or clopidogrel use and mild traumatic intracranial hemorrhage may be at increased risk for unfavorable long-term neurological outcomes compared with similar patients without preinjury use of these medications. To our knowledge, this is the first study to evaluate the effect of preinjury anticoagulant or antiplatelet use on longer-term outcomes in older adults with TBI.
Both cohorts demonstrated a high proportion of
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Cited by (28)
Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series
2022, InjuryCitation Excerpt :Finally we do not know how well anticoagulants were used, it is known that patients on anticoagulants frequently have a sub-therapeutic INR. [24] However, although anticoagulant use was not a risk factor for traumatic findings in the current study, a low threshold for scanning these patients should be considered in our opinion because traumatic findings may have a worse outcome in the presence of anticoagulant use. [25–27] Scanning all patients on anticoagulant therapy would (at a 3% predicted-risk scanning-threshold) lead to 81 extra CTs and a reduction of two patients with missed traumatic findings (sensitivity 92%; specificity 25%).
Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit
2022, World NeurosurgeryCitation Excerpt :Despite the focus of this study and our population inclusion criteria, the distribution of age was normal, with a full range of geriatric cases represented and no significant age-dependent outliers. On the other hand, studies have also shown poor outcomes among geriatric patients with TBI on antithrombotic therapy.32,33 Our results showed no significant direct correlation between any pretraumatic medical therapy and poor patient outcomes.
Risk of Intracranial Hemorrhage and Short-Term Outcome in Patients with Minor Head Injury
2020, World NeurosurgeryCitation Excerpt :This association is most relevant in patients with mild traumatic brain injury.12 A prospective, observational study of 1064 patients with blunt head trauma and preinjury warfarin or clopidogrel use at 2 trauma centers and 4 community hospitals demonstrated that patients receiving clopidogrel have a significantly higher prevalence of immediate tICH compared with patients receiving warfarin.13 Delayed tICH is rare but occurred only in patients receiving warfarin.
Impact of a routine neurosurgical dispatch on emergency air medical transport and outcome of patients with intracranial hemorrhage
2020, Journal of the Formosan Medical AssociationCitation Excerpt :Patients <80 years had a lower risk of 90-day mortality than patients aged ≥81 years, similar to previous studies.15,16 In addition, patients who are anticoagulated and suffer blunt head trauma appear to have a two times higher risk of death compared to a similar cohort without anticoagulation.17–19 The process of aging, superimposed disease states, and poly-pharmacy in elderly patients may lead to death not from direct consequences of their injury but from inexplicable sequential organ failure.
Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management
2017, The Lancet NeurologyCitation Excerpt :According to a meta-analysis,49 patients taking warfarin at the time of TBI have double the risk of poor outcome than patients not taking warfarin, but a similar analysis of antiplatelet therapy did not show a clear increase in risk.50 Although retrospective evidence echoes this observation,52 other studies51,54,55 have suggested that preinjury use of antiplatelet therapy could result in a two-times higher occurrence of traumatic ICH even after mild TBI than in patients not taking antiplatelet therapy, particularly in the elderly population. Preinjury clopidogrel or warfarin intake are independent predictors of immediate traumatic ICH, disease progression, and worse outcomes.56–58
Anticoagulation Therapy in Traumatic Brain Injury
2016, World NeurosurgeryCitation Excerpt :Patients who are anticoagulated and experience blunt head trauma appear to have 2 times higher risk of death compared with a similar cohort without OAT.4 In particular, elderly patients with preinjury OAT and mild traumatic ICH may be at an increased risk for worse long-term neurologic outcomes.5 The risk of developing a chronic subdural hematoma (cSDH) was at least 42.5 times higher in warfarinized patients6; however, there are discrepancies among reports on the risk of cSDH after OAT or antiplatelet agents (AA) ranging from 0.02% to 41%.7-9
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Source of funding: DN was supported through a Mentored Clinical Research Training Program Award (grant UL1TR000002 and linked award KL2TR000134) from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. NCATS and NIH had no role in the design and conduct of the study, in the analysis or interpretation of the data, or in the preparation of the data. The views expressed in this article are solely the responsibility of the authors and do not necessarily represent the official view of NCATS or NIH. Information on NCATS is available at http://www.ncats.nih.gov/. Information on Re-engineering the Clinical Research Enterprise can be obtained from http://nihroadmap.nih.gov/clinicalresearch/overview-translational.asp.