Risk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use

doi:10.1016/j.ajem.2013.04.035

The American Journal of Emergency Medicine

Volume 31, Issue 8, August 2013, Pages 1244-1247

https://doi.org/10.1016/j.ajem.2013.04.035 Get rights and content

Abstract

Study objective

The objective was to compare neurological outcomes at 6 months in older patients with preinjury warfarin or clopidogrel use and mild traumatic intracranial hemorrhage with those without prior use of these medications.

Methods

This was a retrospective study conducted at a Level 1 trauma center from April 2009 to July 2010. Patients older than 55 years with isolated mild head injury (Glasgow Coma Scale score 13-15 and Abbreviated Injury Score < 3 in nonhead body region) were included. Demographic, clinical, and outcome data were abstracted from an existing traumatic brain injury database. The primary end point of unfavorable extended Glasgow Outcome Score at 6 months was compared between patients with and without preinjury warfarin or clopidogrel use.

Results

Seventy-seven eligible patients were identified: 27 (35%) with preinjury warfarin or clopidogrel use and 50 (65%) without. Baseline characteristics (sex, Glasgow Coma Scale score, Injury Severity Score, computed tomography score, and in-hospital mortality) were similar between cohorts, although the preinjury warfarin or clopidogrel cohort was older than the control group (P < .05). Patients in the preinjury warfarin or clopidogrel cohort were more likely to have an unfavorable outcome (16/27; 59.3%; 95% confidence interval, 40.7%-77.8%) as compared with those without (18/50; 36.0%; 95% confidence interval, 22.7%-49.3%) (P = .05).

Conclusion

Older adults with preinjury warfarin or clopidogrel use and mild traumatic intracranial hemorrhage may be at an increased risk for unfavorable long-term neurological outcomes compared with similar patients without preinjury use of these medications.

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.

Section snippets

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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Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use
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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, Injury
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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%).
To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI).
The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic.
Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69–0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74–0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%).
Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.
Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit
2022, World Neurosurgery
Citation 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.
Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207).
Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge.
Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes.
Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.
Risk of Intracranial Hemorrhage and Short-Term Outcome in Patients with Minor Head Injury
2020, World Neurosurgery
Citation 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.
To examine the occurrence of traumatic intracranial hemorrhage (tICH) and outcome in patients with minor head injury and assess the probable risk factors.
Patients with minor head injury who visited our hospital from January 2015 to July 2017 were registered consecutively, and enrolled patients were aged ≥18 years, visited within 24 hours of the injury, and had a Glasgow Coma Scale score of 15 at outpatient clinic or before the injury.
Of the 1122 enrolled patients, 55 (4.9%) had tICH. An antiplatelet agent was administered in 114 patients, an anticoagulant agent was administered in 49 patients, and none of them were administered in 948 patients. A multivariate analysis of tICH identified it as a risk factor, showing significant difference between antiplatelet medication (P = 0.0312), fall from stairs (P = 0.0057), traffic accident (P = 0.0117), neurologic symptoms (P = 0.0091), and modified Rankin Scale (mRS) score before trauma (P < 0.0001). We also analyzed association of enlargement of tICH with different parameters and only anticoagulant medication indicated an increased risk (P = 0.0005). Thirty patients (2.6%) were dependent or died at discharge (mRS 3–6). The mRS score before trauma (P < 0.0001), tICH (P < 0.0001), spinal injury (P < 0.0001), and enlargement of intracranial hemorrhage (P = 0.0008) indicated an increased probability of morbidity (mRS 3–6) in multivariate analysis.
Antiplatelet and anticoagulant medications were risk factor for tICH and enlargement of tICH in patients with minor head injury, respectively. A pretrauma condition of disability/dependence is an important risk factor for tICH and outcome.
Impact of a routine neurosurgical dispatch on emergency air medical transport and outcome of patients with intracranial hemorrhage
2020, Journal of the Formosan Medical Association
Citation 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.
Emergency air medical transport (EAMT) of patients in remote areas with neurological emergencies to higher-level facilities is an integral part of the regionalized healthcare system. EAMT is safe and feasible for head injuries. Debates persist on the high cost, safety, and risk of EAMT, thereby calling for alternatives.
We conducted a retrospective cohort study by including all patients with intracranial hemorrhage (ICH) who visited the Kinmen Hospital from January 2006 to December 2016. Routine neurosurgical dispatch (RNSD) implemented since 2009, dispatches neurosurgeons to Kinmen. EAMT and 90-day mortality were assessed.
We enrolled 560 patients: 173 pre-stage and 387 post-stage. RNSD resulted in less EAMT deployment ([adjusted odds ratio AOR] = 0·23, p < 0·001) and lower 90-day mortality ([adjusted hazard ratio AHR] 0·66, p = 0·043). RNSD resulted in decreased EAMT among all subgroups, especially in age ≥81 years (AOR 0.03, p < 0.001), age 41–60 years (AOR 0.10, p < 0.001), traumatic intracranial hemorrhage (TICH) (AOR 0·11, p < 0·001), and Glasgow Coma Scale (GCS) 9–12 (AOR 0.14, p 0.001). The risk of 90-day mortality was higher in male (AHR 1.81, p = 0·006), GCS 3–8 (AHR 35.52, p < 0·001) and GCS 9–12 (AHR 7.46, p < 0·01) and lower in age 21–40 years (AHR 0.46, p = 0.034).
Incorporating RNSD with EAMT is a plausible alternative to EAMT with a significant decrease in EAMT and decreased 90-day mortality in patients with ICH compared with non-neurosurgical care with EAMT. Despite a 34% decrease in 90-day mortality after RNSD, patient characteristics such as disease severity, age, and sex still dictated patient outcomes.
Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management
2017, The Lancet Neurology
Citation 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
Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.
Anticoagulation Therapy in Traumatic Brain Injury
2016, World Neurosurgery
Citation 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
Optimal anticoagulation therapy (AT) in patients with traumatic brain injury (TBI) is a challenging task and proper management is strongly correlated with clinical outcomes. Only limited data are available on AT after TBI and practical decision making is based on the opinion of experts. This review sought to critically assess different therapeutic options using AT and antiplatelet agents in the perioperative period after TBI.
A comprehensive review of the literature was performed to summarize relevant data on AT in patients with TBI.
Patients with preinjury AT with TBI require emergent neurosurgical treatment and they are also at high risk of developing thromboembolic complications or hematoma expansion. New oral anticoagulants offer a lower incidence of intracranial hemorrhage compared with warfarin. The rate of intracranial hemorrhage during new oral anticoagulants or heparin therapy is significantly lower than that with vitamin K antagonists.

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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.

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Brief ReportRisk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use☆

Abstract

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study design and setting

Selection of participants

Results

Discussion

Injury

Management of prehospital antiplatelet and anticoagulant therapy in traumatic head injury: a review

J Trauma

Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use

Ann Emerg Med

Use of factor IX complex in warfarin-related intracranial hemorrhage

Neurosurgery

Management of intracranial hemorrhage associated with anticoagulant therapy

Surg Neurol

Chronic subdural hematoma: study of 161 patients and the relationship with coagulation abnormalities

Arq Neuropsiquiatr

Traumatic head injury in the anticoagulated elderly patient: a lethal combination

Am Surg

Preinjury warfarin use among elderly patients with closed head injuries in a trauma center

J Trauma

Brief Report
Risk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use☆