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Internal and Emergency Medicine

, Volume 13, Issue 7, pp 1077–1087 | Cite as

Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists

  • Alessandro Cipriano
  • Alessio Pecori
  • Alessandra Eugenia Bionda
  • Michele Bardini
  • Francesca Frassi
  • Francesco Leoli
  • Valentina Lami
  • Lorenzo Ghiadoni
  • Massimo Santini
EM - ORIGINAL

Abstract

Prognosis after mild traumatic brain injury (MTBI) on oral anticoagulant therapy (OAT) is uncertain. We evaluated the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) and the safety of a clinical management protocol. In this single-center prospective observational study, we enrolled 220 patients on OAT with MTBI. After a first negative CT scan, asymptomatic patients underwent a close neurological observation; if neurologically stable, they were discharged without a second CT scan and followed up for 1 month. Out of the 220 patients, 206 met the inclusion criteria. 23 of them (11.2%) had a positive first CT scan for ICH. Only 1 (0.5%, 95% CI 0.0–1.4%) died because of ICH; no one required neurosurgical intervention. The observed prevalence rate of immediate ICH resulted statistically higher in VKAs-treated patients compared to those treated with DOACs (15.7 vs. 4.7%, RR 3.34, 95% CI 1.18–9.46, P < 0.05). In the 1-month follow-up, 5 out of the 183 patients with a negative CT scan were lost. Out of the remaining 178 patients, only 3 showed a delayed ICH (1.7%, 95% CI 0.0–3.6%), 1 of them died (0.6%, 95% CI 0.5–1.7%) and the others did not require neurosurgical intervention. DOACs resulted safer than VKAs also in the setting of MTBI. In our observation, the rate of delayed hemorrhage was relatively low. Patients presenting with a negative first CT scan and without neurological deterioration could be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan.

Keywords

Mild traumatic brain injury Anticoagulation Direct oral anticoagulants Intracranial hemorrhage 

Abbreviations

OAT

Oral anticoagulation therapy

TBI

Traumatic brain injury

ICH

Intracranial hemorrhage

MTBI

Mild traumatic brain injury

GCS

Glasgow Coma Scale

CT

Computed tomography

VKAs

Vitamin K antagonists

DOACs

Direct oral anticoagulants

EFNS

European Federation of Neurological Societies

NICE

National Institute for Health and Care Excellence

ED

Emergency department

LOC

Loss of consciousness

INR

International normalized ratio

ERD

Emergency radiology division

PTA

Post-traumatic amnesia

aPTT

Activated partial thromboplastin time

PT

Prothrombin Time

SD

Standard deviation

IQR

Inter quartile range

3F-PCC

3-Factor prothrombin complex concentrate

LMWH

Low molecular weight heparin

ASA

Acetyl salicylic acid

Notes

Acknowledgements

The statistical analysis of this manuscript was performed by Dr. Andrea Ripoli.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed consent

All the patients in the study signed an informed consent and cannot be identified in the text or images.

Supplementary material

11739_2018_1806_MOESM1_ESM.docx (108 kb)
Supplementary material 1 (DOCX 108 kb)
11739_2018_1806_MOESM2_ESM.sav (47 kb)
Supplementary material 2 (SAV 47 kb)
11739_2018_1806_MOESM3_ESM.pdf (31 kb)
Supplementary material 3 (PDF 31 kb)

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Copyright information

© SIMI 2018

Authors and Affiliations

  • Alessandro Cipriano
    • 1
  • Alessio Pecori
    • 1
  • Alessandra Eugenia Bionda
    • 1
  • Michele Bardini
    • 1
  • Francesca Frassi
    • 1
  • Francesco Leoli
    • 1
  • Valentina Lami
    • 1
  • Lorenzo Ghiadoni
    • 2
  • Massimo Santini
    • 1
  1. 1.Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d’Urgenza e Pronto SoccorsoAzienda Ospedaliero-Universitaria PisanaPisaItaly
  2. 2.Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d’Urgenza UniversitariaAzienda Ospedaliero-Universitaria PisanaPisaItaly

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