Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
European Journal of Trauma and Emergency Surgery
Published in: European Journal of Trauma and Emergency Surgery 6/2022

Open Access 22-06-2022 | Central Nervous System Trauma | Original Article

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study

Authors: Tomas Vedin, Jakob Lundager Forberg, Ebba Anefjäll, Riikka Lehtinen, Mohammed Faisal, Marcus Edelhamre

Published in: European Journal of Trauma and Emergency Surgery | Issue 6/2022

Login to get access

Abstract

Background

Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls.

Methods

This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included.

Results

The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13–2.60) and 1.08 (p = 0.73), (95% CI 0.70–1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02–2.49), p = 0.041).

Conclusion

This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.
Literature
1.
Vedin T, Svensson S, Edelhamre M, Karlsson M, Bergenheim M, Larsson PA. Management of mild traumatic brain injury-trauma energy level and medical history as possible predictors for intracranial hemorrhage. Eur J Trauma Emerg Surg. 2019;45:901–7.CrossRefPubMed
2.
Leach P, Childs C, Evans J, Johnston N, Protheroe R, King A. Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester. Br J Neurosurg. 2007;21:11–5.CrossRefPubMed
3.
Nakahara S, Matsuoka T, Ueno M, Mizushima Y, Ichikawa M, Yokota J, et al. Predictive factors for undertriage among severe blunt trauma patients: what enables them to slip through an established trauma triage protocol. J Trauma. 2010;68:1044–51.PubMed
4.
Paul AB, Oklu R, Saini S, Prabhakar AM. How much is that head CT? Price transparency and variability in radiology. J Am Coll Radiol. 2015;12:453–7.CrossRefPubMed
5.
Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169:2078–86.CrossRefPubMedPubMedCentral
6.
Brenner DJ. Should we be concerned about the rapid increase in CT usage? Rev Environ Health. 2010;25:63–8.CrossRefPubMed
7.
Aygun N, Masaryk TJ. Diagnostic imaging for intracerebral hemorrhage. Neurosurg Clin N Am. 2002;13(313–34):vi.PubMed
8.
9.
Andersson EH, Bjorklund R, Emanuelson I, Stalhammar D. Epidemiology of traumatic brain injury: a population based study in western Sweden. Acta Neurol Scand. 2003;107:256–9.CrossRefPubMed
10.
Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001;357:1391–6.CrossRefPubMed
11.
Hodgkinson S, Pollit V, Sharpin C, Lecky F, National IFHACENICEGDG. Early management of head injury: summary of updated NICE guidance. BMJ. 2014;348:g104.CrossRefPubMed
12.
Unden J, Ingebrigtsen T, Romner B. Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update. BMC Med. 2013;11:50.CrossRefPubMedPubMedCentral
13.
Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(460–468): e7.
14.
Uccella L, Zoia C, Bongetta D, Gaetani P, Martig F, Candrian C, et al. Are antiplatelet and anticoagulants drugs a risk factor for bleeding in mild traumatic brain injury. World Neurosurg. 2018;110:e339–45.CrossRefPubMed
15.
Alter SM, Mazer BA, Solano JJ, Shih RD, Hughes MJ, Clayton LM, et al. Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries. Trauma Surg Acute Care Open. 2020;5: e000520.CrossRefPubMedPubMedCentral
16.
17.
Savioli G, Ceresa IF, Luzzi S, Gragnaniello C, Giotta Lucifero A, Del Maestro M, 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 (Kaunas). 2020. https://​doi.​org/​10.​3390/​medicina56060308​.CrossRefPubMed
18.
Cipriano A, Pecori A, Bionda AE, Bardini M, Frassi F, Leoli F, 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. 2018;13:1077–87.CrossRefPubMed
19.
20.
Turcato G, Zannoni M, Zaboli A, Zorzi E, Ricci G, Pfeifer N, 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.CrossRefPubMed
21.
Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343:100–5.CrossRefPubMed
22.
Barbosa RR, Jawa R, Watters JM, Knight JC, Kerwin AJ, Winston ES, et al. Evaluation and management of mild traumatic brain injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S307–14.CrossRefPubMed
23.
Fakhry SM, Morse JL, Garland JM, Wilson NY, Shen Y, Wyse RJ, et al. Antiplatelet and anticoagulant agents have minimal impact on traumatic brain injury incidence, surgery, and mortality in geriatric ground level falls: a multi-institutional analysis of 33,710 patients. J Trauma Acute Care Surg. 2021;90:215–23.CrossRefPubMed
24.
Starmark JE, Stålhammar D, Holmgren E, Rosander B. A comparison of the glasgow coma scale and the reaction level scale (RLS85). J Neurosurg. 1988;69:699–706.CrossRefPubMed
25.
Johnstone AJ, Lohlun JC, Miller JD, McIntosh CA, Gregori A, Brown R, et al. A comparison of the glasgow coma scale and the swedish reaction level scale. Brain Inj. 1993;7:501–6.CrossRefPubMed
26.
Yoon SJ, Kim EJ, Seo HJ, Oh IH. The association between charlson comorbidity index and the medical care cost of cancer: a retrospective study. Biomed Res Int. 2015;2015: 259341.CrossRefPubMedPubMedCentral
27.
Sundararajan V, Henderson T, Perry C, Muggivan A, Quan H, Ghali WA. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol. 2004;57:1288–94.CrossRefPubMed
28.
Charlson ME, Charlson RE, Peterson JC, Marinopoulos SS, Briggs WM, Hollenberg JP. The Charlson comorbidity index is adapted to predict costs of chronic disease in primary care patients. J Clin Epidemiol. 2008;61:1234–40.CrossRefPubMed
29.
Fraccaro P, Kontopantelis E, Sperrin M, Peek N, Mallen C, Urban P, et al. Predicting mortality from change-over-time in the Charlson Comorbidity Index: a retrospective cohort study in a data-intensive UK health system. Medicine (Baltimore). 2016;95: e4973.CrossRefPubMed
30.
Vassar M, Holzmann M. The retrospective chart review: important methodological considerations. J Educ Eval Health Prof. 2013;10:12.CrossRefPubMed
31.
Vedin T, Edelhamre M, Karlsson M, Bergenheim M, Larsson PA. Management of traumatic brain injury in the emergency department: guideline adherence and patient safety. Qual Manag Health Care. 2017;26:190–5.CrossRefPubMed
32.
van den Brand CL, Tolido T, Rambach AH, Hunink MG, Patka P, Jellema K. Systematic review and meta-analysis: is pre-injury antiplatelet therapy associated with traumatic intracranial hemorrhage. J Neurotrauma. 2017;34:1–7.CrossRefPubMed
33.
Fuller G, Sabir L, Evans R, Bradbury D, Kuczawski M, Mason SM. Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis. Emerg Med J. 2020;37:666–73.CrossRefPubMed
Metadata
Title
Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study
Authors
Tomas Vedin
Jakob Lundager Forberg
Ebba Anefjäll
Riikka Lehtinen
Mohammed Faisal
Marcus Edelhamre
Publication date
22-06-2022
Publisher
Springer Berlin Heidelberg
Published in
European Journal of Trauma and Emergency Surgery / Issue 6/2022
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI
https://doi.org/10.1007/s00068-022-02016-8

Other articles of this Issue 6/2022

European Journal of Trauma and Emergency Surgery 6/2022 Go to the issue

Original Article

Traumatic brain injury with concomitant injury to the spleen: characteristics and mortality of a high-risk trauma cohort from the TraumaRegister DGU®

Original Article

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS

Original Article

Proximal humeral fracture osteosynthesis in Belgium: a retrospective population-based epidemiologic study

Original Article

Development of practical triage methods for critical trauma patients: machine-learning algorithm for evaluating hybrid operation theatre entry of trauma patients (THETA)

Original Article

Perioperative and oncologic outcomes of interval colectomy performed by acute care surgeons after stenting as a bridge to surgery for left-sided malignant colonic obstruction are non-inferior to the outcomes of colorectal surgeons in the elective setting: single center experience

Original Article

Epidemiology of clavicle shaft fractures in a public hospital in South Africa: differences between developing and developed countries