nach oben

16.05.2024 | Review

Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis

verfasst von: Armin Karamian, Ali Seifi, Amin Karamian, Brandon Lucke-Wold

Einloggen, um Zugang zu erhalten

Abstract

Background

Traumatic brain injury (TBI) is one of the leading causes of disability and death worldwide. Most TBI cases occur in older people, because they are at a higher risk of accidental falling. As the population ages, the use of anticoagulants is increasing. Some serious complications of TBI, such as intracranial hemorrhage (ICH), may occur even in mild cases. According to the current guidelines regarding managing mild TBI patients, a CT head scan is recommended for all patients receiving anticoagulation. We aim to assess the incidence of ICH in patients with mild TBI taking oral anticoagulants.

Methods

Our systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The protocol was registered in PROSPERO (CRD42024503086). Twenty-eight studies evaluating patients with a mild TBI from ten countries with a total sample size of 11,172, 5671 on DOACs, and 5501 on VKAs were included in our meta-analysis.

Results

The random-effects overall incidence of ICH among oral anticoagulated patients with mild TBI was calculated to be 9.4% [95% CI 7.2–12.1%, I² = 89%]. The rates of immediate ICH for patients taking DOACs and VKAs were 6.4% and 10.5%, respectively. The overall rate of immediate ICH in anticoagulated mild TBI patients was 8.5% [95% CI 6.6–10.9%], with a high heterogeneity between studies (I² = 88%). Furthermore, the rates of delayed ICH in patients with mild TBI taking DOACs and VKAs were 1.6% and 1.9%, respectively. The overall incidence of delayed ICH among oral anticoagulated mild TBI patients was 1.7% [95% CI 1–2.8%, I² = 79%]. The overall rate of ICH among mild TBI patients taking DOAC was calculated to be 7.3% [95% CI 5.2–10.3%], with significant heterogeneity between studies (I² = 79%). However, the overall ICH rate is higher in patients who take only VKAs 11.3% [95% CI 8.6–14.7%, I² = 83%]. Patients on DOACs were at lower risk of ICH after mild TBI compared to patients on VKAs (OR = 0.64, 95% CI 0.48–0.86, p < 0.01, I² = 28%).

Conclusion

Our meta-analysis confirms the need for performing brain CT scan in patients with mild TBI patients who receive oral anticoagulants before injury. Due to limited data, further multi-center, prospective studies are warranted to confirm the true incidence of traumatic ICH in patients on anticoagulants.

Nur mit Berechtigung zugänglich

Ng SY, Lee AYW (2019) Traumatic brain injuries: pathophysiology and potential therapeutic targets. Front Cell Neurosci 13:528PubMedPubMedCentralCrossRef

Bauersachs RM, Herold J (2020) Oral anticoagulation in the elderly and frail. Hamostaseologie 40(1):74–83PubMedCrossRef

Gardner RC et al (2018) Geriatric traumatic brain injury: epidemiology, outcomes, knowledge gaps, and future directions. J Neurotrauma 35(7):889–906PubMedPubMedCentralCrossRef

(2003) The Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem is a publication of the National Center for Injury Prevention and Control, part of the Centers for Disease Control and Prevention

Savioli G et al (2020) Mild head trauma in elderly patients: experience of an emergency department. Heliyon 6(7):e04226PubMedPubMedCentralCrossRef

Papa L, Mendes ME, Braga CF (2012) Mild traumatic brain injury among the geriatric population. Curr Transl Geriatr Exp Gerontol Rep 1(3):135–142PubMedPubMedCentralCrossRef

Susman M et al (2002) Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 53(2):219–223PubMedCrossRef

Riva N, Ageno W (2015) Pros and cons of vitamin K antagonists and non-vitamin K antagonist oral anticoagulants. Semin Thromb Hemost 41(2):178–187PubMedCrossRef

Ferri N et al (2022) Drug–drug interactions of direct oral anticoagulants (DOACs): from pharmacological to clinical practice. Pharmaceutics 14(6):1120PubMedPubMedCentralCrossRef

10.

Milling TJ Jr, Ziebell CM (2020) A review of oral anticoagulants, old and new, in major bleeding and the need for urgent surgery. Trends Cardiovasc Med 30(2):86–90PubMedCrossRef

11.

Flaherty M et al (2007) The increasing incidence of anticoagulant-associated intracerebral hemorrhage. Neurology 68(2):116–121PubMedCrossRef

12.

Schols AM et al (2014) Incidence of oral anticoagulant-associated intracerebral hemorrhage in the Netherlands. Stroke 45(1):268–270PubMedCrossRef

13.

Ikram MA, Wieberdink RG, Koudstaal PJ (2012) International epidemiology of intracerebral hemorrhage. Curr Atheroscler Rep 14:300–306PubMedPubMedCentralCrossRef

14.

Morotti A, Goldstein JN (2020) Anticoagulant-associated intracerebral hemorrhage. Brain Hemorrhages 1(1):89–94CrossRef

15.

Stiell IG et al (2001) The Canadian CT Head Rule for patients with minor head injury. Lancet 357(9266):1391–1396PubMedCrossRef

16.

Campiglio L et al (2017) Mild brain injury and anticoagulants: less is enough. Neurol Clin Pract 7(4):296–305PubMedPubMedCentralCrossRef

17.

Hofmann V et al (2021) Mild traumatic brain injury in older adults: are routine second cCT scans necessary? J Clin Med 10(17):3794PubMedPubMedCentralCrossRef

18.

Battle B, Sexton KW, Fitzgerald RT (2018) Understanding the value of repeat head CT in elderly trauma patients on anticoagulant or antiplatelet therapy. J Am Coll Radiol 15(2):319–321PubMedCrossRef

19.

Cipriano A et al (2018) Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists. Intern Emerg Med 13(7):1077–1087PubMedCrossRef

20.

Melsen WG et al (2014) The effects of clinical and statistical heterogeneity on the predictive values of results from meta-analyses. Clin Microbiol Infect 20(2):123–129PubMedCrossRef

21.

Cipriano A et al (2021) Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med 16(4):1061–1070PubMedCrossRef

22.

Spinola MB et al (2019) Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants. Am J Emerg Med 37(9):1677–1680PubMedCrossRef

23.

Nishijima DK et al (2012) Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 59(6):460-8.e1–7PubMedPubMedCentralCrossRef

24.

Menditto VG et al (2012) Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 59(6):451–455PubMedCrossRef

25.

de Wit K et al (2023) Derivation of the falls decision rule to exclude intracranial bleeding without head CT in older adults who have fallen. CMAJ 195(47):E1614-e1621PubMedPubMedCentralCrossRef

26.

Fuller GW et al (2019) Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review. Ann Emerg Med 73(1):66–75PubMedCrossRef

27.

Colas L et al (2023) Limited benefit of systematic head CT for mild traumatic brain injury in patients under antithrombotic therapy. J Neuroradiol 50(1):30–35PubMedCrossRef

28.

Özensoy HS et al (2023) Determining the risk of development of cranial pathology in patients with minor head injury using antiagregan-anticoagulants. Arch Curr Med Res 4(2):102–112CrossRef

29.

Swap C et al (2016) Risk of delayed intracerebral hemorrhage in anticoagulated patients after minor head trauma: the role of repeat cranial computed tomography. Perm J 20(2):14–16PubMedPubMedCentralCrossRef

30.

Brewer ES et al (2011) Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J Trauma 70(1):E1-5PubMed

31.

Alrajhi KN, Perry JJ, Forster AJ (2015) Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 48(2):137–142PubMedCrossRef

32.

Pozzessere A, Grotts J, Kaminski S (2015) Dabigatran use does not increase intracranial hemorrhage in traumatic geriatric falls when compared with warfarin. Am Surg 81(10):1039–1042PubMedCrossRef

33.

Savioli G et al (2020) 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 (Kaunas) 56(6):308PubMedCrossRef

34.

Turcato G et al (2019) 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 57(6):817–824PubMedCrossRef

35.

Galliazzo S et al (2019) Intracranial bleeding risk after minor traumatic brain injury in patients on antithrombotic drugs. Thromb Res 174:113–120PubMedCrossRef

36.

Benedetti S et al (2023) In old anticoagulated patients with mild traumatic brain injury, a 24-h observation period should not be recommended without evidence of a clear benefit: a retrospective study of delayed hemorrhagic versus iatrogenic complications. Intern Emerg Med 19(2):523–534PubMedCrossRef

37.

O’Brien T et al (2020) Clinically significant traumatic intracranial hemorrhage following minor head trauma in older adults: a retrospective cohort study. Brain Inj 34(6):834–839PubMed

38.

Schindler CR et al (2023) Cranial CT is a mandatory tool to exclude asymptomatic cerebral hemorrhage in elderly patients on anticoagulation. Front Med (Lausanne) 10:1117777PubMedCrossRef

39.

Uccella L et al (2018) Are antiplatelet and anticoagulants drugs a risk factor for bleeding in mild traumatic brain injury? World Neurosurg 110:e339–e345PubMedCrossRef

40.

McCammack KC et al (2015) Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury. West J Emerg Med 16(1):43–49PubMedCrossRef

41.

Cipriano A et al (2023) Minimal is not minor also in patients with mild traumatic brain injury on oral direct anticoagulant therapy. Intern Emerg Med 18(5):1533–1541PubMedCrossRef

42.

Jentzsch T et al (2018) Is rivaroxaban associated with higher morbidity and mortality in patients with traumatic head injuries? A retrospective cohort study comparing rivaroxaban, no anticoagulation, and phenprocoumon. Clin Neurol Neurosurg 169:116–120PubMedCrossRef

43.

Vedin T et al (2022) Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study. Eur J Trauma Emerg Surg 48(6):4909–4917PubMedPubMedCentralCrossRef

44.

Cocca AT et al (2019) Delayed intracranial hemorrhage in anticoagulated geriatric patients after ground level falls. J Emerg Med 57(6):812–816PubMedCrossRef

45.

Turcato G et al (2022) Decision tree analysis for assessing the risk of post-traumatic haemorrhage after mild traumatic brain injury in patients on oral anticoagulant therapy. BMC Emerg Med 22(1):47PubMedPubMedCentralCrossRef

46.

Sakkas A et al (2023) Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit. Eur J Trauma Emerg Surg 50(1):157–172PubMedCrossRef

47.

Minhas H et al (2018) Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies. Br J Haematol 183(1):119–126PubMedCrossRef

48.

Fiorelli EM et al (2020) Incremental risk of intracranial hemorrhage after mild traumatic brain injury in patients on antiplatelet therapy: systematic review and meta-analysis. J Emerg Med 59(6):843–855PubMedCrossRef

49.

Turcato G et al (2022) Risk of delayed intracranial haemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury. Am J Emerg Med 53:185–189PubMedCrossRef

50.

Chauny JM et al (2016) Risk of delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: systematic review and meta-analysis. J Emerg Med 51(5):519–528PubMedCrossRef

51.

Verschoof MA et al (2018) 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 265(2):315–321PubMedCrossRef

52.

Fujita S et al (2023) Characterization of brain volume changes in aging individuals with normal cognition using serial magnetic resonance imaging. JAMA Netw Open 6(6):e2318153PubMedPubMedCentralCrossRef

53.

Kamel H et al (2016) Atrial fibrillation and mechanisms of stroke. Stroke 47(3):895–900PubMedPubMedCentralCrossRef

54.

Watson N, Bonsack F, Sukumari-Ramesh S (2022) Intracerebral hemorrhage: the effects of aging on brain injury. Front Aging Neurosci 14:859067PubMedPubMedCentralCrossRef

55.

Borst J et al (2021) Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery 170(2):623–627PubMedCrossRef

Titel: Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis
verfasst von: Armin Karamian
Ali Seifi
Amin Karamian
Brandon Lucke-Wold
Publikationsdatum: 16.05.2024
Verlag: Springer Berlin Heidelberg
Erschienen in: Journal of Neurology
Print ISSN: 0340-5354
Elektronische ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-024-12424-y

Leitlinien kompakt für die Neurologie

Mit medbee Pocketcards sicher entscheiden.

^{Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag}

Kostenlos registrieren

Neu im Fachgebiet Neurologie

Nicht Creutzfeldt Jakob, sondern Abführtee-Vergiftung

29.05.2024 Hyponatriämie Nachrichten

Eine ältere Frau trinkt regelmäßig Sennesblättertee gegen ihre Verstopfung. Der scheint plötzlich gut zu wirken. Auf Durchfall und Erbrechen folgt allerdings eine Hyponatriämie. Nach deren Korrektur kommt es plötzlich zu progredienten Kognitions- und Verhaltensstörungen.

Schutz der Synapsen bei Alzheimer

29.05.2024 Morbus Alzheimer Nachrichten

Mit einem Neurotrophin-Rezeptor-Modulator lässt sich möglicherweise eine bestehende Alzheimerdemenz etwas abschwächen: Erste Phase-2-Daten deuten auf einen verbesserten Synapsenschutz.

Sozialer Aufstieg verringert Demenzgefahr

24.05.2024 Demenz Nachrichten

Ein hohes soziales Niveau ist mit die beste Versicherung gegen eine Demenz. Noch geringer ist das Demenzrisiko für Menschen, die sozial aufsteigen: Sie gewinnen fast zwei demenzfreie Lebensjahre. Umgekehrt steigt die Demenzgefahr beim sozialen Abstieg.

Hirnblutung unter DOAK und VKA ähnlich bedrohlich

17.05.2024 Direkte orale Antikoagulanzien Nachrichten

Kommt es zu einer nichttraumatischen Hirnblutung, spielt es keine große Rolle, ob die Betroffenen zuvor direkt wirksame orale Antikoagulanzien oder Marcumar bekommen haben: Die Prognose ist ähnlich schlecht.

Update Neurologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen