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Are oral anticoagulants a risk factor for mild traumatic brain injury progression? A single-center experience focused on of direct oral anticoagulants and vitamin K antagonists

  • Original Article - Brain trauma
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Mild traumatic brain injury (TBI) in anticoagulated patients is a common challenge for emergency departments because of lack of appropriate epidemiological data and huge management variability for those under oral anticoagulation therapy.

Given the discrepancies between guidelines, the aim of the present study was to quantify the association between oral anticoagulant therapy (either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC)) and the post-traumatic intracranial hemorrhage worsening compared to admission CT scan.

Methods

We included all consecutive records of patients admitted to our emergency department for mild TBI as chief complaint and with a positive admission CT scan. After statistical univariate comparison, cause-specific hazard ratio (HR) and 95% confidence interval (CI) were determined with the use of Cox proportional hazard model.

Results

In the study period, 4667 patients had a CT scan for mild TBI; 439 (9.4%) were found to have intracranial hemorrhage. Among these patients, 299 (68.1%) were prescribed observation and control CT: 46 (15.38%) were on anticoagulant therapy, 23 (50%) on VKA, and 23 (50%) on DOAC. In multivariate analysis, only oral anticoagulation therapy was significantly associated to an increased risk of intracranial hemorrhage progression (HR 2.58; 95% CI 1.411–4.703; p = .002 and HR 1.9; 95% CI 1.004–3.735; p = .0048 for VKA and DOAC, respectively). Surgery was due to isolated subdural hematoma in 87.5% of cases, to subdural hematoma associated with intraparenchymal hemorrhage in 9.38% and to intraparenchymal hemorrhage only in 3.12%; 13 cases (4.35%) deceased in intensive care unit.

Conclusions

In our series, anticoagulation was associated to a significant increase in intracranial progression, leaving the question open as to what this implies in current clinical practice; subdural hematoma was the major finding associated to evolution and surgery. Against this background, further studies are needed to clarify patients’ management and DOAC safety profile compared to VKA in mild TBI.

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Data availability

The dataset that supports the findings of this study are available from the corresponding author, G.M, upon reasonable request.

Abbreviations

CT:

Computed tomography

DOAC:

Direct oral anticoagulants

VKA:

Vitamin K antagonist

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Author notes

  1. Giuseppe Maria Della Pepa and Marcello Covino are authors equally contributed to the manuscript.

Authors and Affiliations

  1. Institute of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, 8, 00168, Rome, Italy

    Giuseppe Maria Della Pepa, Grazia Menna, Anna Maria Auricchio, Filippo Maria Polli & Alessandro Olivi

  2. Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy

    Marcello Covino, Alberto Manno, Benedetta Simeoni & Francesco Franceschi

  3. Università Cattolica del Sacro Cuore, Rome, Italy

    Marcello Covino

Authors
  1. Giuseppe Maria Della Pepa
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  2. Marcello Covino
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  3. Grazia Menna
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  4. Anna Maria Auricchio
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  9. Francesco Franceschi
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Contributions

Giuseppe Maria Della Pepa and Marcello Covino contributed to the study conception and design. Data collection was performed by Grazia Menna, Annamaria Auricchio, Alberto Manno, and Benedetta Simeoni. Data analysis was performed by Marcello Covino. The first draft of the manuscript was written by Giuseppe Maria Della Pepa and Grazia Menna. Filippo Maria Polli, Alessandro Olivi, and Francesco Franceschi supervised the work. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Grazia Menna.

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Ethics approval

Ethical approval was waived by the local Ethics Committee in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

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Being a retrospective analysis based on a digital anonymized database, patient’s informed consent was waived.

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Additional informed consent regarding publishing their data was obtained by all individual participants. The author transfers the publication rights and warrant that her contribution is original and that she has full power to make this grant. The author signs for and accepts responsibility for releasing this material on behalf of any and all co-authors.

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The authors declare no competing interests.

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This article is part of the Topical Collection on Brain trauma

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Della Pepa, G.M., Covino, M., Menna, G. et al. Are oral anticoagulants a risk factor for mild traumatic brain injury progression? A single-center experience focused on of direct oral anticoagulants and vitamin K antagonists. Acta Neurochir 164, 97–105 (2022). https://doi.org/10.1007/s00701-021-05066-w

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