The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department
https://doi.org/10.4081/ecj.2022.10640
Accepted: 14 June 2022
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The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice.
Gelbard R, Inaba K, Okoye OT, et al. Falls in the elderly: A modern look at an old problem. Am J Surg 2014;208:249-53. DOI: https://doi.org/10.1016/j.amjsurg.2013.12.034
TAaRN. Major trauma in older people. Salford, UK: University of Manchester, Manchester Academic Health Science Centre, 2018. Available from: https://www.tarn.ac.uk/content/downloads/3793/Major%20Trauma%20in%20Older%20People%202017.pdf
Prisco D, Ageno W, Becattini C, et al. Italian intersociety consensus on DOAC use in internal medicine. Intern Emerg Med 2017;12:387-406. DOI: https://doi.org/10.1007/s11739-017-1628-6
Pieracci FM, Eachempati SR, Shou J, et al. 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 2007;63:519-24. DOI: https://doi.org/10.1097/TA.0b013e31812e519b
Spaniolas K, Cheng JD, Gestring ML, et al. Ground level falls are associated with significant mortality in elderly patients. J Trauma 2010;69:821-5. DOI: https://doi.org/10.1097/TA.0b013e3181efc6c6
Dossett LA, Riesel JN, Griffin MR, Cotton BA. Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank. Arch Surg 2011;146:565-70. DOI: https://doi.org/10.1001/archsurg.2010.313
Nishijima DK, Shahlaie K, Sarkar K, et al. Risk of unfavorable long-term outcome in older adults with traumatic intracranial hemorrhage and anticoagulant or antiplatelet use. Am J Emerg Med 2013;31:1244-7. DOI: https://doi.org/10.1016/j.ajem.2013.04.035
Collins CE, Witkowski ER, Flahive JM, et alP. Effect of preinjury warfarin use on outcomes after head trauma in Medicare beneficiaries. Am J Surg 2014;208:544-9 e1. DOI: https://doi.org/10.1016/j.amjsurg.2014.05.019
Vos PE, Battistin L, Birbamer G, et al. EFNS guideline on mild traumatic brain injury: Report of an EFNS task force. Eur J Neurol 2002;9:207-19. DOI: https://doi.org/10.1046/j.1468-1331.2002.00407.x
Davis T, Ings A, National Institute of H, Care E. Head injury: Triage, assessment, investigation and early management of head injury in children, young people and adults (NICE guideline CG 176). Arch Dis Child Educ Pract Ed 2015;100:97-100. DOI: https://doi.org/10.1136/archdischild-2014-306797
Mower WR, Hoffman JR, Herbert M, et al. Developing a clinical decision instrument to rule out intracranial injuries in patients with minor head trauma: Methodology of the NEXUS II investigation. Ann Emerg Med 2002;40:505-14. DOI: https://doi.org/10.1067/mem.2002.129245
Smits M, Dippel DW, Steyerberg EW, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: The CHIP prediction rule. Ann Intern Med 2007;146:397-405. DOI: https://doi.org/10.7326/0003-4819-146-6-200703200-00004
Firsching R, Rickels E, Mauer UM, et al. Guidelines for the treatment of head injury in adults. J Neurol Surg A Cent Eur Neurosurg 2017;78:478-87. DOI: https://doi.org/10.1055/s-0037-1599239
Stiell IG, Lesiuk H, Wells GA, et al. The Canadian CT Head Rule Study for patients with minor head injury: Rationale, objectives, and methodology for phase I (derivation). Ann Emerg Med 2001;38:160-9. DOI: https://doi.org/10.1067/mem.2001.116796
Alzuhairy AKA. Accuracy of Canadian CT Head Rule and New Orleans Criteria for Minor Head Trauma; A systematic review and meta-analysis. Arch Acad Emerg Med 2020;8:e79.
Minhas H, Welsher A, Turcotte M, et al. Incidence of intracranial bleeding in anticoagulated patients with minor head injury: A systematic review and meta-analysis of prospective studies. Br J Haematol 2018;183:119-26. DOI: https://doi.org/10.1111/bjh.15509
Grandhi R, Harrison G, Voronovich Z, et al. Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients. J Trauma Acute Care Surg 2015;78:614-21. DOI: https://doi.org/10.1097/TA.0000000000000542
Jeffree RL, Gordon DH, Sivasubramaniam R, Chapman A. Warfarin related intracranial haemorrhage: A case-controlled study of anticoagulation monitoring prior to spontaneous subdural or intracerebral haemorrhage. J Clin Neurosci 2009;16:882-5. DOI: https://doi.org/10.1016/j.jocn.2008.10.004
Riccardi A, Guiddo G, Chiarbonello B, et al. Minor head injury in anticoagulated patients: A 6-year retrospective analysis in an emergency department. Emerg Care J 2014;10:1913. DOI: https://doi.org/10.4081/ecj.2014.1913
Galliazzo S, Bianchi MD, Virano A, et al. Intracranial bleeding risk after minor traumatic brain injury in patients on antithrombotic drugs. Thromb Res 2019;174:113-20. DOI: https://doi.org/10.1016/j.thromres.2018.12.015
Nishijima DK, Gaona SD, Waechter T, et al. The incidence of traumatic intracranial hemorrhage in head-injured older adults transported by EMS with and without anticoagulant or antiplatelet use. J Neurotrauma 2018;35:750-9. DOI: https://doi.org/10.1089/neu.2017.5232
Turcato G, Zaboli A, Pfeifer N, et al. Decision tree analysis to predict the risk of intracranial haemorrhage after mild traumatic brain injury in patients taking DOACs. Am J Emerg Med 2021;50:388-93. DOI: https://doi.org/10.1016/j.ajem.2021.08.048
Kuczawski M, Stevenson M, Goodacre S, et al. Should all anticoagulated patients with head injury receive a CT scan? Decision-analysis modelling of an observational cohort. BMJ Open 2016;6:e013742. DOI: https://doi.org/10.1136/bmjopen-2016-013742
Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 2015;48:137-42. DOI: https://doi.org/10.1016/j.jemermed.2014.08.016
Lampart A, Kuster T, Nickel CH, et al. Prevalence and severity of traumatic intracranial hemorrhage in older adults with low-energy falls. J Am Geriatrics Soc 2020;68:977-82. DOI: https://doi.org/10.1111/jgs.16400
Uccella L, Zoia C, Bongetta D, et al. Are antiplatelet and anticoagulants drugs a risk factor for bleeding in mild traumatic brain injury? World Neurosurg 2018;110:e339-e45. DOI: https://doi.org/10.1016/j.wneu.2017.10.173
Fuller GW, Evans R, Preston L, et al. Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review. Ann Emerg Med 2019;73:66-75. DOI: https://doi.org/10.1016/j.annemergmed.2018.07.020
Nederpelt CJ, van der Aalst SJM, Rosenthal MG, et al. Consequences of pre-injury utilization of direct oral anticoagulants in patients with traumatic brain injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2020;88:186-94. DOI: https://doi.org/10.1097/TA.0000000000002518
Turcato G, Zannoni M, Zaboli A, et al. 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 2019;57:817-24. DOI: https://doi.org/10.1016/j.jemermed.2019.09.007
Cipriano A, Park N, Pecori A, et al. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med 2021;16:1061-70. DOI: https://doi.org/10.1007/s11739-020-02576-w
Mason S, Kuczawski M, Teare MD, et al. AHEAD Study: An observational study of the management of anticoagulated patients who suffer head injury. BMJ Open 2017;7:e014324. DOI: https://doi.org/10.1136/bmjopen-2016-014324
Chai-Adisaksopha C, Hillis C, Isayama T, et al. Mortality outcomes in patients receiving direct oral anticoagulants: A systematic review and meta-analysis of randomized controlled trials. J Thromb Haemostasis 2015;13:2012-20. DOI: https://doi.org/10.1111/jth.13139
Dentali F, Riva N, Crowther M, et al. Efficacy and safety of the novel oral anticoagulants in atrial fibrillation: A systematic review and meta-analysis of the literature. Circulation 2012;126:2381-91. DOI: https://doi.org/10.1161/CIRCULATIONAHA.112.115410
Spinola MB, Riccardi A, Minuto P, et al. Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants. Am J Emerg Med 2019;37:1677-80. DOI: https://doi.org/10.1016/j.ajem.2018.12.003
Prexl O, Bruckbauer M, Voelckel W, et al. The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old. Scand J Trauma Resusc Emerg Med 2018;26:20. DOI: https://doi.org/10.1186/s13049-018-0487-0
Batey M, Hecht J, Callahan C, Wahl W. Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly. Surgery 2018;164:814-9. DOI: https://doi.org/10.1016/j.surg.2018.05.060
Caldeira D, Barra M, Pinto FJ, et al. Intracranial hemorrhage risk with the new oral anticoagulants: a systematic review and meta-analysis. J Neurol 2015;262:516-22. DOI: https://doi.org/10.1007/s00415-014-7462-0
Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet 2014;383:955-62. DOI: https://doi.org/10.1016/S0140-6736(13)62343-0
van Es N, Coppens M, Schulman S, et al. Direct oral anticoagulants compared with vitamin K antagonists for acute venous thromboembolism: Evidence from phase 3 trials. Blood 2014;124:1968-75. DOI: https://doi.org/10.1182/blood-2014-04-571232
Cipriano A, Pecori A, Bionda AE, et al. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists. Internal Emerg Med 2018;13:1077-87. DOI: https://doi.org/10.1007/s11739-018-1806-1
Wilson D, Seiffge DJ, Traenka C, et al. Outcome of intracerebral hemorrhage associated with different oral anticoagulants. Neurol 2017;88:1693-700. DOI: https://doi.org/10.1212/WNL.0000000000003886
Savioli G, Ceresa IF, Luzzi S, et al. Rates of intracranial hemorrhage in mild head trauma patients presenting to emergency department and their management: A comparison of direct oral anticoagulant drugs with vitamin K antagonists. Medicina 2020;56:308. DOI: https://doi.org/10.3390/medicina56060308
Santing JAL, Van den Brand CL, Jellema K. Traumatic brain injury in patients receiving direct oral anticoagulants. J Emerg Med 2021;60:285-91. DOI: https://doi.org/10.1016/j.jemermed.2020.09.012
Zeeshan M, Jehan F, O'Keeffe T, et al. The novel oral anticoagulants (NOACs) have worse outcomes compared with warfarin in patients with intracranial hemorrhage after TBI. J Trauma Acute Care Surg 2018;85:915-20. DOI: https://doi.org/10.1097/TA.0000000000001995
Reynolds FD, Dietz PA, Higgins D, Whitaker TS. Time to deterioration of the elderly, anticoagulated, minor head injury patient who presents without evidence of neurologic abnormality. J Trauma 2003;54:492-6. DOI: https://doi.org/10.1097/01.TA.0000051601.60556.FC
Kaen A, Jimenez-Roldan L, Arrese I, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma 2010;68:895-8. DOI: https://doi.org/10.1097/TA.0b013e3181b28a76
Mourad M, Senay A, Kharbutli B. The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs). Injury 2021;52:2571-5. DOI: https://doi.org/10.1016/j.injury.2021.05.039
Mann N, Welch K, Martin A, et al. Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emerg Med 2018;18:27. DOI: https://doi.org/10.1186/s12873-018-0179-0
Barmparas G, Kobayashi L, Dhillon NK, et al. The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: A two-center study. Am J Surg 2019;217:1051-4. DOI: https://doi.org/10.1016/j.amjsurg.2018.10.016
Cohan CM, Beattie G, Dominguez DA, et al. Routine repeat head CT does not change management in trauma patients on novel anticoagulants. J Surg Res 2020;249:114-20. DOI: https://doi.org/10.1016/j.jss.2019.11.009
Soleimani T, Mosher B, Ochoa-Frongia L, et al. Delayed intracranial hemorrhage after blunt head injury with direct oral anticoagulants. J Surg Res 2021;257:394-8. DOI: https://doi.org/10.1016/j.jss.2020.08.024
Peck KA, Sise CB, Shackford SR, et al. Delayed intracranial hemorrhage after blunt trauma: Are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma 2011;71:1600-4. DOI: https://doi.org/10.1097/TA.0b013e31823b9ce1
Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8. DOI: https://doi.org/10.1016/j.annemergmed.2012.04.007
Cohn B, Keim SM, Sanders AB. Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med 2014;46:410-7. DOI: https://doi.org/10.1016/j.jemermed.2013.08.107
Chauny JM, Marquis M, Bernard F, et al. Risk of delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: Systematic review and meta-analysis. J Emerg Med 2016;51:519-28. DOI: https://doi.org/10.1016/j.jemermed.2016.05.045
Uccella L, Zoia C, Perlasca F, et al. Mild traumatic brain injury in patients on long-term anticoagulation therapy: Do they really need repeated head CT scan? World Neurosurg 2016;93:100-3. DOI: https://doi.org/10.1016/j.wneu.2016.05.061
Lim BL, Manauis C, Asinas-Tan ML. Outcomes of warfarinized patients with minor head injury and normal initial CT scan. Am J Emerg Med 2016;34:75-8. DOI: https://doi.org/10.1016/j.ajem.2015.09.009
Campiglio L, Bianchi F, Cattalini C, et al. Mild brain injury and anticoagulants: Less is enough. Neurol Clinical Pract 2017;7:296-305. DOI: https://doi.org/10.1212/CPJ.0000000000000375
Verschoof MA, Zuurbier CCM, de Beer F, et al. Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: A retrospective multicenter study and meta-analysis. J Neurol 2018;265:315-21. DOI: https://doi.org/10.1007/s00415-017-8701-y
Afaneh A, Ford J, Gharzeddine J, et al. Head injury on Warfarin: Likelihood of delayed intracranial bleeding in patients with negative initial head CT. BMC Res Notes 2018;11:183. DOI: https://doi.org/10.1186/s13104-018-3291-z
McCammack KC, Sadler C, Guo Y, Ramaswamy RS, Farid N. Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury. Western J Emerg Med 2015;16:43-9. DOI: https://doi.org/10.5811/westjem.2014.10.19488
Huang JL, Woehrle TA, Conway P, et al. Evaluation of a protocol for early detection of delayed brain hemorrhage in head injured patients on warfarin. Eur J Trauma Emerg Surg 2019;45:481-7. DOI: https://doi.org/10.1007/s00068-018-0924-9
Hickey S, Hickman ZL, Conway J, Giwa A. The effect of direct oral anti-coagulants on delayed traumatic intracranial hemorrhage after mild traumatic brain injury: A systematic review. J Emerg Med 2021;60:321-30. DOI: https://doi.org/10.1016/j.jemermed.2020.10.037
Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol. Ann Emerg Med 2012;59:451-5. DOI: https://doi.org/10.1016/j.annemergmed.2011.12.003
Marques RSF, Antunes C, Machado MJ, et al. Reappraising the need for a control CT in mild head injury patients on anticoagulation. Eur J Trauma Emerg Surg 2021;47:1461-6. DOI: https://doi.org/10.1007/s00068-019-01172-8
Li J. Admit all anticoagulated head-injured patients? A million dollars versus your dime. You make the call. Ann Emerg Med 2012;59:457-9. DOI: https://doi.org/10.1016/j.annemergmed.2012.01.010
Kehoe A, Smith JE, Bouamra O, et al. Older patients with traumatic brain injury present with a higher GCS score than younger patients for a given severity of injury. Emerg Med J 2016;33:381-5. DOI: https://doi.org/10.1136/emermed-2015-205180
Bobeff EJ, Fortuniak J, Bryszewski B, et al. Mortality after traumatic brain injury in elderly patients: a new scoring system. World Neurosurg 2019;128:e129-e47. DOI: https://doi.org/10.1016/j.wneu.2019.04.060
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