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

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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.

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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

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Acknowledgements

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

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Authors and Affiliations

  1. Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d’Urgenza e Pronto Soccorso, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy

    Alessandro Cipriano, Alessio Pecori, Alessandra Eugenia Bionda, Michele Bardini, Francesca Frassi, Francesco Leoli, Valentina Lami & Massimo Santini

  2. Emergency Department, Nuovo Santa Chiara Hospital, U.O. Medicina d’Urgenza Universitaria, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy

    Lorenzo Ghiadoni

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  1. Alessandro Cipriano
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Correspondence to Alessandro Cipriano.

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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.

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Cipriano, A., Pecori, A., Bionda, A.E. et al. Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists. Intern Emerg Med 13, 1077–1087 (2018). https://doi.org/10.1007/s11739-018-1806-1

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