Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients

Clinical outcome and prognostic factors in elderly traumatic brain injury patients receiving neurointensive care

Background

The probability of favorable outcome after traumatic brain injury (TBI) decreases with age. Elderly, ≥ 60 years, are an increasing part of our population. Recent studies have shown an increase of favorable outcome in elderly over time. However, the optimal patient selection and neurointensive care (NIC) treatments may differ in the elderly and the young. The aims of this study were to examine outcome in a larger group of elderly TBI patients receiving NIC and to identify demographic and treatment related prognostic factors.

Methods

Patients with TBI ≥ 60 years receiving NIC at our department between 2008 and 2014 were included. Demographics, co-morbidity, admission characteristics, and type of treatments were collected. Clinical outcome at around 6 months was assessed. Potential prognostic factors were included in univariate and multivariate regression analysis with favorable outcome as dependent variable.

Results

Two hundred twenty patients with mean age 70 years (median 69; range 60–87) were studied. Overall, favorable outcome was 46% (Extended Glasgow Outcome Scale (GOSE) 5–8), unfavorable outcome 27% (GOSE 2–4), and mortality 27% (GOSE 1). Significant independent negative prognostic variables were high age (p < 0.05), multiple injuries (p < 0.05), GCS M ≤ 3 on admission (p < 0.05), and mechanical ventilation (p < 0.001).

Conclusions

Overall, the elderly TBI patients > 60 years receiving modern NIC in this study had a fair chance of favorable outcome without large risks for severe deficits and vegetative state, also in patients over 75 years of age. High age, multiple injuries, GCS M ≤ 3 on admission, and mechanical ventilation proved to be independent negative prognostic factors. The results underline that a selected group of elderly with TBI should have access to NIC.

Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System

BACKGROUND

Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization.

METHODS

To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection.

RESULTS

The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 10⁹ cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics.

CONCLUSIONS

The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Impact of frailty and anticoagulation status on readmission and mortality rates following falls in patients over 80

Falls are the leading cause of trauma-related mortality in geriatric patients. We hypothesized that frailty and anticoagulation status are risk factors for readmission and mortality following falls in patients >80 years. A retrospective review was performed on patients over 80 years old who presented to our level 1 trauma center for a fall and underwent a computed tomography of the head between January 2014 and January 2016. Frailty was assessed via the Rockwood Frailty Score. Clinical outcomes were death, readmission, recurrent falls, and delayed intracranial hemorrhage. Of 803 fall-related encounters, 173 patients over 80 years old were identified for inclusion. The 30-day readmission rate was 17.5% and was associated with an increased 6-month mortality (P = 0.01). One-year and 2-year mortality rates were 28% and 47%, respectively. Frailty was the strongest predictor of 6-month and overall mortality (P < 0.01). Anticoagulation status did not significantly influence these outcomes. The recurrent fall rate was 21%, and delayed intracranial hemorrhage did not occur in this study. Mortality of octogenarians after a fall is most influenced by patient frailty. Acknowledgment of frailty, risk of recurrent falls, and increased mortality should direct goals of care for geriatric trauma patients.

Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement

There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.

Intensive Care Unit Admission Patterns for Mild Traumatic Brain Injury in the USA

BACKGROUND

Patients with mild traumatic brain injury (TBI) are frequently admitted to an intensive care unit (ICU), but routine ICU use may be unnecessary. It is not clear to what extent this practice varies between hospitals.

METHODS

We conducted a retrospective cohort study using the National Trauma Data Bank. Patients with at least one TBI ICD-9-CM diagnosis code, a head abbreviated injury score (AIS) ≤ 4, and Glasgow coma scale (GCS) ≥ 13 were included; individuals with only a concussion and those with a non-head AIS > 2 were excluded. Primary outcomes were ICU admission and "overtriage" to the ICU, defined by: ICU stay ≤ 1 day; hospital stay ≤ 2 days; no intubation; no neurosurgery; and discharged to home. Mixed effects multivariable models were used to identify patient and facility characteristics associated with these outcomes.

RESULTS

A total of 595,171 patients were included, 44.7% of whom were admitted to an ICU; 17.3% of these met the criteria for overtriage. Compared with adults, children < 2 years were more likely to be admitted to an ICU (RR 1.21, 95% CI 1.16-1.26) and to be overtriaged (RR 2.06, 95% CI 1.88-2.25). Similarly, patients with isolated subarachnoid hemorrhage were at greater risk of both ICU admission (RR 2.36, 95% CI 2.31-2.41) and overtriage (RR 1.22, 95% CI 1.17-1.28). The probabilities of ICU admission and overtriage varied as much as 16- and 11-fold across hospitals, respectively; median risk ratios were 1.67 and 1.53, respectively. The likelihood of these outcomes did not vary substantially with the characteristics of the treating facility.

CONCLUSIONS

There is considerable variability in ICU admission practices for mild TBI across the USA, and some of these patients may not require ICU-level care. Refined ICU use in mild TBI may allow for reduced resource utilization without jeopardizing patient outcomes.

Bleeding and Thromboembolism After Traumatic Brain Injury in the Elderly: A Real Conundrum

BACKGROUND

Elderly patients presenting with a traumatic brain injury (TBI) often have comorbidities that increase risk of thromboembolic (TE) disease and recurrent TBI. A significant number are on anticoagulant therapy at the time of injury and studies suggest that continuing anticoagulation can prevent TE events. Understanding bleeding, recurrent TBI, and TE risk after TBI can help to guide therapy. Our objectives were to 1) evaluate the incidence of bleeding, recurrent TBI, and TE events after an initial TBI in older adults and 2) identify which factors contribute to this risk.

METHODS

Retrospective analysis of Medicare claims between May 30, 2006 and December 31, 2009 for patients hospitalized with TBI was performed. We defined TBI for the index admission, and hemorrhage (gastrointestinal bleeding or hemorrhagic stroke), recurrent TBI, and TE events (stroke, myocardial infarction, deep venous thrombosis, or pulmonary embolism) over the following year using ICD-9 codes. Unadjusted incidence rates and 95% confidence intervals (CIs) were calculated. Risk factors of these events were identified using logistic regression.

RESULTS

Among beneficiaries hospitalized with TBI, incidence of TE events (58.6 events/1000 person-years; 95% CI 56.2, 60.8) was significantly higher than bleeding (23.6 events/1000 person-years; 95% CI 22.2, 25.1) and recurrent TBI events (26.0 events/1000 person-years; 95% CI 24.5, 27.6). Several common factors predisposed to bleeding, recurrent TBI, and TE outcomes.

CONCLUSIONS

Among Medicare patients hospitalized with TBI, the incidence of TE was significantly higher than that of bleeding or recurrent TBI. Specific risk factors of bleeding and TE events were identified which may guide care of older adults after TBI.

Investigation of risk factors of geriatric patients with significant brain injury from ground-level fall: A retrospective cohort study in a local Accident and Emergency Department setting

Background:

Trauma was the fifth leading cause of death in Hong Kong in 2013.4 Injuries caused by falls ranked first in traumatic brain injury (TBI) cases among older adults (51%).5 Elderly trauma patients face an increased risk of adverse consequences6 from trauma compared with their younger counterparts, as advanced age itself is already a well-recognized risk factor for less favorable outcomes following trauma. Therefore, identifying factors associated with significant brain injury in geriatric patients in A&E triage is crucial in providing timely care to these patients.

Objectives:

To identify the risk factors for geriatric patients with significant brain injury from ground-level falls and to formulate their association of risk factors with significant brain injury as a consequence from ground-level falls.

Methods:

This was a retrospective study with data collected from the Clinical Data Analysis and Reporting System of Queen Mary Hospital from 1 January 2013 to 31 December 2015. A total of 1101 cases were identified.

Results:

There were 76% of the recruited patients with a normal computed tomography scan. However, the remaining 24% had computed tomography scans indicative of brain injury. Severe head injuries were scored 3 -8 on the Glasgow Coma Scale and moderate head injuries were scored 9 -12. Respectively, these were 20 times (p = 0.005) and 5 times (p = 0.002) more likely to have positive computed tomography findings than patients with a Glasgow Coma Scale score from 13 to 15. Patients with loss of consciousness were two times more likely to have a positive computed tomography result than those without loss of consciousness (p = 0.001). Although warfarin use is a well-established risk factor for intracranial hemorrhage after head injury, in our dataset, the result was not statistically significant. However, the use of new oral anti-coagulants was associated with positive computed tomography findings with patients taking new oral anti-coagulants 2.3 times more likely to have positive computed tomography findings compared with those with no anticoagulant use (p = 0.033).

Conclusions:

Early detection of patients with significant brain injury and aggressive management may prevent secondary injury from the complications of brain injury, hence improving patient mortality and morbidity, and reducing hospital stay and health care costs.

Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly

BACKGROUND

Falls are now the leading cause of trauma and represent the most common type of trauma in the elderly. The use of anticoagulants is increasing in older patients, but there are little data on outcomes after traumatic brain injury while anticoagulated with direct oral anticoagulants compared with warfarin. We hypothesized that anticoagulated patients would have a greater mortality and complications than nonanticoagulated patients, and patients on direct oral anticoagulants would have more fatal outcomes after low-level falls because of lack of reversal agents.

METHODS

Patients 65 years or older admitted to level 1-3 trauma centers with 24-hour neurosurgical care were identified through the administrative database of 19 Trinity Health hospitals. Patients with International Classification of Diseases, Ninth Revision, codes consistent with low-level fall and traumatic brain injury from May 2013 through October 2015 were included. Preadmission warfarin or direct oral anticoagulant use was extracted from admission reconciliation of medications in the database.

RESULTS

A total of 700 patients met inclusion criteria with 177 on anticoagulants before admission. Anticoagulated patients had more cardiac (P < .001), pulmonary (P < .001), and clotting (P < .02) comorbidities. Warfarin patients had the greatest neurosurgical intervention rate at 18% compared with direct oral anticoagulants (2.8%, P < .02) or nonanticoagulation (11%, P < .02). No difference was identified in overall mortality and mortality after neurosurgical intervention between the nonanticoagulated, warfarin, or direct oral anticoagulant groups. Warfarin patients received more plasma (P < .001) and red cell transfusions (P = .035) with greater intensive care unit stays (P < .001) compared with direct oral anticoagulant or nonanticoagulated patients. With logistic regression, only advancing age (P < .05) and a lesser Glasgow Coma Scale score (P < .01) were associated with greater mortality.

CONCLUSION

Older direct oral anticoagulant patients with traumatic brain injury after low-level fall did not have increased morbidity or mortality compared with those treated with warfarin or who were not treated with anticoagulants. Concerns over the use of direct oral anticoagulant agents in this population may be overstated and deserve more scrutiny.

Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage?

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P < 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P < 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit.

Clinical Outcome of Epidural Hematoma Treated Surgically in the Era of Modern Resuscitation and Trauma Care

OBJECTIVE

Patients from contemporary populations with traumatic brain injury (TBI) resulting from epidural hematoma (EDH) may differ regarding age, comorbidities, and coagulation status. We therefore analyzed predictors for the clinical outcome of patients with EDH treated surgically regarding modern approaches to resuscitation and trauma care.

METHODS

A retrospective observational analysis was carried out. All patients included underwent surgery. The indication for surgery followed international guidelines. Retrospective data evaluation considered data reflecting the effectiveness of trauma care, baseline characteristics, and radiologic findings. In this analysis, we divided patients into 2 groups (isolated EDH vs. EDH plus other intracranial traumatic injuries). The neurologic outcome was assessed at discharge using the Glasgow Outcome Scale.

RESULTS

Two hundred and sixty-eight patients with epidural hematoma, of whom 131 underwent surgery, were treated between January 1997 and December 2012 in our level-1 trauma center. The overall mortality was 6.8% (mortality for patients with Glasgow Outcome Scale score <9, 15%). As expected, factors with a highly significant (P < 0.01) impact on outcome were concomitant with other intracranial injuries, brain midline shift, and higher Injury Severity Score. Alcohol intoxication was a significant (P < 0.05) predictor of an unfavorable outcome. Anticoagulants and Glasgow Coma Scale score at admission had no significant impact on the outcome.

CONCLUSIONS

The outcome for EDH is more favorable than decades ago, most probably reflecting a well-established chain of trauma care. Therefore, EDH is a treatable disease with a high probability of a favorable outcome.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

Background

Traumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. There is a paucity of data about the role of direct oral anticoagulants (DOACs) among TBI patients.

Methods

In this retrospective study, we investigated all TBI patients ≥60-years-old who were admitted to the intensive care unit (ICU) from January 2014 until May 2017. Patients were grouped into those receiving vitamin K antagonists (VKA), platelet inhibitors (PI), DOACs and no antithrombotic therapy (no-ATT).

Results

One-hundred-eighty-six, predominantly male (52.7%) TBI patients with a median age of 79 years (range: 70–85 years) were enrolled in the study. Glasgow Coma Scale and S-100β were not different among the groups. Patients on VKA and DOACs had a higher Charlson Comorbidity Index compared to the PI group and no-ATT group (p = 0.0021). The VKA group received reversal agents significantly more often than the other groups (p < 0.0001). Haematoma progression in the follow-up cranial computed tomography (CCT) was lowest in the DOAC group. The number of CCT and surgical interventions were low with no differences between the groups. No relevant differences in ICU and hospital length of stay were observed. Mortality in the VKA group was significantly higher compared to DOAC, PI and no-ATT group (p = 0.047).

Discussion

Data from huge registry studies displayed higher efficacy and lower fatal bleeding rates for DOACs compared to VKAs. The current study revealed comparable results. Despite the fact that TBI patients on VKAs received reversal agents more often than patients on DOACs (84.4% vs. 24.2%, p < 0.001), mortality rate was significantly higher in the VKA group (p = 0.047).

Conclusion

In patients ≥60 years suffering from TBI, anticoagulation with DOACs appears to be safer than with VKA. Anti-thrombotic therapy with VKA resulted in a worse outcome compared to DOACs and PI. Further studies are warranted to confirm this finding.

Patients with Moderate and Severe Traumatic Brain Injury: Impact of Preinjury Platelet Inhibitor or Warfarin Treatment

OBJECTIVE

We aimed to examine the effect of preinjury antithrombotic medication on clinical and radiologic neuroworsening in traumatic brain injury (TBI) and study the effect on outcome.

METHODS

A total of 184 consecutive patients ≥50 years old with moderate and severe TBI admitted to a level 1 trauma center were included. Neuroworsening was assessed clinically by using the Glasgow Coma Scale (GCS) score and radiologically by using the Rotterdam CT score on repeated time points. Functional outcome was assessed with the Glasgow Outcome Scale Extended 6 months after injury.

RESULTS

The platelet inhibitor group (mean age, 77.3 years; n = 43) and the warfarin group (mean age, 73.2 years; n = 20) were significantly older than the nonuser group (mean age, 63.7 years; n = 121; P ≤ 0.001). In the platelet inhibitor group 74% and in the warfarin group, 85% were injured by falls. Platelet inhibitors were not significantly associated with clinical or radiologic neuroworsening (P = 0.37-1.00), whereas warfarin increased the frequency of worsening in GCS score (P = 0.001-0.028) and Rotterdam CT score (P = 0.004). In-hospital mortality was higher in the platelet inhibitor group (28%; P = 0.030) and the warfarin group (50%; P < 0.001) compared with the nonuser group (13%). Platelet inhibitors did not predict mortality or worse outcome after adjustment for age, preinjury disability, GCS score, and Rotterdam CT score, whereas warfarin predicted both mortality and worse outcome.

CONCLUSIONS

In this study of patients with moderate and severe TBI, preinjury platelet inhibitors did not cause neuroworsening or predict higher mortality or worse outcome. In contrast, preinjury warfarin caused neuroworsening and was an independent risk factor for mortality and worse outcome at 6 months. Hence, fall prevention and liberal use of computed tomography examinations is important in this patient group.

Coagulopathy induced by traumatic brain injury: systemic manifestation of a localized injury

Traumatic brain injury (TBI)-induced coagulopathy is a common and well-recognized risk for poor clinical outcomes, but its pathogenesis remains poorly understood, and treatment options are limited and ineffective. We discuss the recent progress and knowledge gaps in understanding this lethal complication of TBI. We focus on (1) the disruption of the brain-blood barrier to disseminate brain injury systemically by releasing brain-derived molecules into the circulation and (2) TBI-induced hypercoagulable and hyperfibrinolytic states that result in persistent and delayed intracranial hemorrhage and systemic bleeding.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

Risk of Intracranial Hemorrhage in Ground-level Fall With Antiplatelet or Anticoagulant Agents

OBJECTIVES

Anticoagulant and antiplatelet medications are known to increase the risk and severity of traumatic intracranial hemorrhage (tICH), even with minor head trauma. Most studies on bleeding propensity with head trauma are retrospective, are based on trauma registries, or include heterogeneous mechanisms of injury. The goal of this study was to determine the rate of tICH from only a common low-acuity mechanism of injury, that of a ground-level fall, in patients taking one or more of the following antiplatelet or anticoagulant medications: aspirin, warfarin, prasugrel, ticagrelor, dabigatran, rivaroxaban, apixaban, or enoxaparin.

METHODS

This was a prospective cohort study conducted at a Level I tertiary care trauma center of consecutive patients meeting the inclusion criteria of a ground-level fall with head trauma as affirmed by the treating clinician, a computed tomography (CT) head obtained, and taking and one of the above antiplatelet or anticoagulants. Patients were identified prospectively through electronic screening with confirmatory chart review. Emergency department charts were abstracted without subsequent knowledge of the hospital course. Patients transferred with a known abnormal CT head were excluded. Primary outcome was rate of tICH on initial CT head. Rates with 95% confidence intervals (CIs) were compared.

RESULTS

Over 30 months, we enrolled 939 subjects. The mean ± SD age was 78.3 ± 11.9 years and 44.6% were male. There were a total of 33 patients with tICH (3.5%, 95% CI = 2.5%-4.9%). Antiplatelets had a rate of tICH of 4.3% (95% CI = 3.0%-6.2%) compared to anticoagulants with a rate of 1.7% (95% CI = 0.4%-4.5%). Aspirin without other agents had an tICH rate of 4.6% (95% CI = 3.2%-6.6%); of these, 81.5% were taking low-dose 81 mg aspirin. Two patients received a craniotomy (one taking aspirin, one taking warfarin). There were four deaths (three taking aspirin, one taking warfarin). Most (72.7%) subjects with tICH were discharged home or to a rehabilitation facility. There were no tICH in 31 subjects taking a direct oral anticoagulant. CIs were overlapping for the groups.

CONCLUSION

There is a low incidence of clinically significant tICH with a ground-level fall in head trauma in patients taking an anticoagulant or antiplatelet medication. There was no statistical difference in rate of tICH between antiplatelet and anticoagulants, which is unanticipated and counterintuitive as most literature and teaching suggests a higher rate with anticoagulants. A larger data set is needed to determine if small differences between the groups exist.

Acute Management of Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of death and disability in patients with trauma. Management strategies must focus on preventing secondary injury by avoiding hypotension and hypoxia and maintaining appropriate cerebral perfusion pressure (CPP), which is a surrogate for cerebral blood flow. CPP can be maintained by increasing mean arterial pressure, decreasing intracranial pressure, or both. The goal should be euvolemia and avoidance of hypotension. Other factors that deserve important consideration in the acute management of patients with TBI are venous thromboembolism, stress ulcer, and seizure prophylaxis, as well as nutritional and metabolic optimization.

Novel oral anticoagulants and trauma: The results of a prospective American Association for the Surgery of Trauma Multi-Institutional Trial

BACKGROUND

The number of anticoagulated trauma patients is increasing. Trauma patients on warfarin have been found to have poor outcomes, particularly after intracranial hemorrhage (ICH). However, the effect of novel oral anticoagulants (NOAs) on trauma outcomes is unknown. We hypothesized that patients on NOAs would have higher rates of ICH, ICH progression, and death compared with patients on traditional anticoagulant and antiplatelet agents.

METHODS

This was a prospective observational trial across 16 trauma centers. Inclusion criteria was any trauma patient admitted on aspirin, clopidogrel, warfarin, dabigatran, rivaroxaban, or apixaban. Demographic data, admission vital signs, mechanism of injury, injury severity scores, laboratory values, and interventions were collected. Outcomes included ICH, progression of ICH, and death.

RESULTS

A total of 1,847 patients were enrolled between July 2013 and June 2015. Mean age was 74.9 years (SD ± 13.8), 46% were female, 77% were non-Hispanic white. At least one comorbidity was reported in 94% of patients. Blunt trauma accounted for 99% of patients, and the median Injury Severity Score was 9 (interquartile range, 4-14). 50% of patients were on antiplatelet agents, 33% on warfarin, 10% on NOAs, and 7% on combination therapy or subcutaneous agents.Patients taking NOAs were not at higher risk for ICH on univariate (24% vs. 31%) or multivariate analysis (incidence rate ratio, 0.78; confidence interval 0.61-1.01, p = 0.05). Compared with all other agents, patients on aspirin (90%, 81 mg; 10%, 325 mg) had the highest rate (35%) and risk (incidence rate ratio, 1.27; confidence interval, 1.13-1.43; p < 0.001) of ICH. Progression of ICH occurred in 17% of patients and was not different between medication groups. Study mortality was 7% and was not significantly different between groups on univariate or multivariate analysis.

CONCLUSION

Patients on NOAs were not at higher risk for ICH, ICH progression, or death.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management

Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.

Relationship between hospital volume and outcomes in patients with traumatic brain injury: A retrospective observational study using a national inpatient database in Japan

BACKGROUND

The relationship between hospital volume and outcome after traumatic brain injury (TBI) is not completely understood in a real clinical setting. We investigated whether patients admitted with TBI achieved better outcomes in high-volume hospitals than in low-volume hospitals using a national inpatient database in Japan.

METHODS

This retrospective cohort study used the Diagnosis Combination Procedure database in Japan. We included patients with TBI admitted to hospitals with a Japan Coma Scale (JCS) score ≥2 between April 1, 2013 and March 31, 2014. Hospital volume was defined as the annual number of all admissions with TBI in individual hospitals. The hospital volume was categorized into four volume groups: low (≤60 admissions per hospital), medium-low (61-120 admissions per hospital), medium-high (121-180 admissions per hospital) and high (≥181 admissions per hospital). The outcomes of interest included 28-day mortality and survival discharge with complete dependency defined as a Barthel Index score of 0 at discharge. We used multivariate logistic regression models fitted with generalized estimating equations to evaluate relationships between the hospital volume and the outcomes. The hospital volume was evaluated both as categorical variables defined above and as continuous variables.

RESULTS

The analysis dataset consisted of 20,146 eligible patients. Of these, 2,784 died within 28days (13.8%) and 3,409 were completely dependent among 16,996 patients discharged alive (20.1%). Multivariate analyses found that there was no significant difference between the high-volume and low-volume groups for 28-day mortality (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.58-1.06 for the high-volume group) or complete dependency at discharge (adjusted OR 0.94, 95% CI 0.71-1.23 for the high-volume group). The results were the same when the hospital volume was evaluated as a continuous variable.

CONCLUSIONS

Hospital volume did not appear to influence outcomes in patients with TBI. High-volume hospitals may not be necessarily beneficial for patients with TBI exhibiting impaired consciousness as a whole.

Point-of-care testing in the acute management of traumatic brain injury: Identifying the coagulopathic patient

Background:

The use of anticoagulants or antiplatelet medications has become increasingly common and is a well-established risk factor for worsening of hemorrhages in trauma patients. The current study addresses the need to investigate the efficacy of point-of-care tests (POC) as an adjunct to conventional coagulation testing in traumatic brain injury (TBI) patients.

Methods:

A retrospective review of 190 TBI patients >18 years of age who underwent both conventional and POC testing as part of their admission coagulopathy workup was conducted. Coagulation deficiency was defined as an international normalized ratio (INR) >1.4, a reaction time (r-value) on rapid thromboelastography >50 seconds, or a VerifyNow Aspirin (VN-ASA) level of < 550 Aspirin Reaction Units.

Results:

Among 190 patients, 91 (48%) disclosed a history of either warfarin or antiplatelet use or had documented INR >1.4. Of the 18 (9%) patients who reported warfarin use, 83% had elevated INR and 61% had elevated r-value. However, 41% of the patients without reported anticoagulant usage revealed significantly elevated r-value consistent with a post-traumatic hypocoagulable state. Of 64 (34%) patients who reported taking ASA, 51 (80%) demonstrated therapeutic VN-ASA. Interestingly, 31 of 126 (25%) patients not reporting ASA use were also noted to have therapeutic VN-ASA suggestive of platelet dysfunction.

Conclusions:

The coagulopathy POC panel consisting of r-TEG and VN-ASA successfully identified a subset of TBI patients with an occult coagulopathy that would have otherwise been missed. Standardization of these POC assays on admission in TBI may help guide patient resuscitation in the acute setting.

Radiologic Findings and Patient Factors Associated with 30-Day Mortality after Surgical Evacuation of Subdural Hematoma in Patients Less Than 65 Years Old

Objective

The purpose of this study is to evaluate the associations between 30-day mortality and various radiological and clinical factors in patients with traumatic acute subdural hematoma (SDH). During the 11-year study period, young patients who underwent surgery for SDH were followed for 30 days. Patients who died due to other medical comorbidities or other organ problems were not included in the study population.

Methods

From January 1, 2004 to December 31, 2014, 318 consecutive surgically-treated traumatic acute SDH patients were registered for the study. The Kaplan–Meier method was used to analyze 30-day survival rates. We also estimated the hazard ratios of various variables in order to identify the independent predictors of 30-day mortality.

Results

We observed a negative correlation between 30-day mortality and Glasgow coma scale score (per 1-point score increase) (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.52–0.70; p<0.001). In addition, use of antithrombotics (HR, 2.34; 95% CI, 1.27–4.33; p=0.008), history of diabetes mellitus (HR, 2.28; 95% CI, 1.20–4.32; p=0.015), and accompanying traumatic subarachnoid hemorrhage (hazard ratio, 2.13; 95% CI, 1.27–3.58; p=0.005) were positively associated with 30-day mortality.

Conclusion

We found significant associations between short-term mortality after surgery for traumatic acute SDH and lower Glasgow Coma Scale scores, use of antithrombotics, history of diabetes mellitus, and accompanying traumatic subarachnoid hemorrhage at admission. We expect these findings to be helpful for selecting patients for surgical treatment of traumatic acute SDH, and for making accurate prognoses.

Early neurological deterioration in older adults with traumatic brain injury

INTRODUCTION

Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity.

METHODS

This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration.

RESULTS

Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AIS_max injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001).

DISCUSSION/CONCLUSIONS

Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.

Safety of Antithrombotic Agents in Elderly Patients with Acute Coronary Syndromes

There are unique challenges in the treatment and prevention of acute coronary syndromes (ACS) with antithrombotics in elderly patients: elderly patients usually require multiple drugs due to comorbidities, are highly susceptible to adverse drug reactions and drug-drug interactions, may have cognitive problems affecting compliance and complications, are especially exposed to the risk of falls and, most importantly, ageing is an independent risk factor for bleeding. Antithrombotic drugs, alone or in association, further and variously amplify age-related bleeding risk. Moreover, age-related changes in primary haemostasis may potentially affect the pharmacodynamics of some antiplatelet drugs. Thus, elderly subjects might be more or less sensitive to standard antiplatelet regimens depending on individual characteristics affecting antiplatelet drug response. Importantly, elderly patients are a rapidly growing population worldwide, have the highest incidence of ACS, but are poorly represented in clinical trials. As a consequence, evidence on antithrombotic drug benefits and risks is limited. Thus, in the real-world setting, older people are often denied antithrombotic drugs because of unjustified concerns, or might be over-treated and exposed to excessive bleeding risk. Personalized antithrombotic therapy in elderly patients is particularly critical, to minimize risks without affecting efficacy.

The older they are the harder they fall: Injury patterns and outcomes by age after ground level falls

BACKGROUND

Trauma centers are seeing an increasing number of geriatric patients that are more susceptible to injuries even from relatively minor insults such as a ground level fall (GLF). As life expectancy increases, people are living in the geriatric age bracket for decades and often use anticoagulation agents for various comorbidities. We hypothesize that this patient population is not homogenous and we investigated the injury patterns and outcomes after GLF as a function of age and anticoagulation use. We also sought to identify injury patterns and patient characteristics of GLF patients.

METHODS

A retrospective review of a Level I trauma center's database identified all adult (age>18) trauma patients admitted after GLFs between 1/2003 and 12/2013. Demographics, injury patterns, antiplatelet use, anticoagulation use (including warfarin, enoxaparin, and rivaroxaban) and outcomes were abstracted.

RESULTS

The cohort included 5088 patients. 3990 patients were >60years and 38.2% were male. With each decade, although the mean ISS did not considerably change (range 7.0-8.6), mortality increased (0.9% at <60years vs. 5.5% at >90years), and the likelihood of home discharge decreased dramatically (73.7% at <60years vs. 18.2% at >90years). Abdominal solid organ injuries were rare (0.8%). Age was associated with an increased incidence of cervical spine (p=0.002), rib (p=0.009) and pelvic fractures (p<0.001). Only aspirin use was significantly associated with intracranial bleed (p=0.001). Aspirin (p=0.049) or warfarin (p<0.001) use was associated with increased overall mortality.

CONCLUSION

GLF patients are not homogenous as certain injury patterns change with increasing age. Aspirin use was associated with an increased incidence of intracranial bleeds, whereas other antiplatelet or anticoagulation agents were not. GLF is also associated with significant morbidity and mortality that increases dramatically with age. Both aspirin and warfarin are independently associated with increased mortality. These patient differences have implications for their evaluation and management.

LEVEL OF EVIDENCE

Epidemiological/prognostic study level IV.

A case of cricothyroidotomy for facial trauma in a patient taking antiplatelet agents after a simple ground-level fall

INTRODUCTION

Cricothyroidotomy is an emergency procedure that can be used to secure the airway in situations in which intubation and ventilation are not possible.

PRESENTATION OF CASE

We describe a case of 79-year-old male presenting with facial trauma combined with massive upper airway bleeding and swelling in which cricothyroidotomy was required to open the airway in an elderly male patient taking antiplatelet agents who suffered a simple ground-level fall.

DISCUSSION

Although emergency airway management is often required in patients with Le Fort fractures, mandibular condyle fractures exhibit a significant relationship with ground-level falls, which are not usually associated with emergency airway management. Prophylactic intubation should be considered prior to transfer or deterioration in a trauma patient with dual antiplatelet drugs and fractures of bilateral mandibular condyle.

CONCLUSION

Clinicians should be aware of the life-threatening injuries that can be caused by simple ground-level falls in patients taking antiplatelet agents.

Mortality among head trauma patients taking preinjury antithrombotic agents: a retrospective cohort analysis from a Level 1 trauma centre

Background

Bleeding represents the most well-known and the most feared complications caused by the use of antithrombotic agents. There is, however, limited documentation whether pre-injury use of antithrombotic agents affects outcome after head trauma. The aim of this study was to define the relationship between the use of preinjury antithrombotic agents and mortality among elderly people sustaining blunt head trauma.

Methods

A retrospective cohort analysis was performed on the hospital based trauma registry at Oslo University Hospital. Patients aged 55 years or older sustaining blunt head trauma between 2004 and 2006 were included. Multivariable logistic regression analyses were used to identify independent predictors of 30-day mortality. Separate analyses were performed for warfarin use and platelet inhibitor use.

Results

Of the 418 patients admitted with a diagnosis of head trauma, 137 (32.8 %) used pre-injury antithrombotic agents (53 warfarin, 80 platelet inhibitors, and 4 both). Seventy patients died (16.7 %); 15 (28.3 %) of the warfarin users, 12 (15.0 %) of the platelet inhibitor users, and two (50 %) with combined use of warfarin and platelet inhibitors, compared to 41 (14.6 %) of the non-users. There was a significant interaction effect between warfarin use and the Triage Revised Trauma Score collected upon the patients’ arrival at the hospital. After adjusting for potential confounders, warfarin use was associated with increased 30-day mortality among patients with normal physiology (adjusted OR 8,3; 95 % CI, 2.0 to 34.8) on admission, but not among patients with physiological derangement on admission. Use of platelet inhibitors was not associated with increased mortality.

Conclusions

The use of warfarin before trauma was associated with increased 30-day mortality among a subset of patients. Use of platelet inhibitors before trauma was not associated with increased mortality. These results indicate that patients on preinjury warfarin may need closer monitoring and follow up after trauma despite normal physiology on admission to the emergency department.

Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis

BACKGROUND

Delayed intracranial hemorrhage is a potential complication of head trauma in anticoagulated patients.

OBJECTIVE

Our aim was to use a systematic review and meta-analysis to determine the risk of delayed intracranial hemorrhage 24 h after head trauma in patients who have a normal initial brain computed tomography (CT) scan but took vitamin K antagonist before injury.

METHODS

EMBASE, Medline, and Cochrane Library were searched using controlled vocabulary and keywords. Retrospective and prospective observational studies were included. Outcomes included positive CT scan 24 h post-trauma, need for surgical intervention, or death. Pooled risk was estimated with logit proportion in a random effect model with 95% confidence intervals (CIs).

RESULTS

Seven publications were identified encompassing 1,594 patients that were rescanned after a normal first head scan. For these patients, the pooled estimate of the incidence of intracranial hemorrhage on the second CT scan 24 h later was 0.60% (95% CI 0-1.2%) and the resulting risk of neurosurgical intervention or death was 0.13% (95% CI 0.02-0.45%).

CONCLUSIONS

The present study is the first published meta-analysis estimating the risk of delayed intracranial hemorrhage 24 h after head trauma in patients anticoagulated with vitamin K antagonist and normal initial CT scan. In most situations, a repeat CT scan in the emergency department 24 h later is not necessary if the first CT scan is normal. Special care may be required for patients with serious mechanism of injury, patients showing signs of neurologic deterioration, and patients presenting with excessive anticoagulation or receiving antiplatelet co-medication.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Is there a difference in efficacy, safety, and cost-effectiveness between 3-factor and 4-factor prothrombin complex concentrates among trauma patients on oral anticoagulants?

PURPOSE

The aim of this study was to compare the efficacy, safety, and cost-effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) vs 4-factor prothrombin complex concentrate PCC (4F-PCC) in trauma patients requiring reversal of oral anticoagulants.

MATERIALS AND METHODS

All consecutive trauma patients with coagulopathy (international normalized ratio [INR] ≥1.5) secondary to oral anticoagulants who received either 3F-PCC or 4F-PCC from 2010 to 2014 at 2 trauma centers were reviewed. Efficacy was determined by assessing the first INR post-PCC administration, and successful reversal was defined as INR less than 1.5. Safety was assessed by reviewing thromboembolic events, and cost-effectiveness was calculated using total treatment costs (drug acquisition plus transfusion costs) per successful reversal.

RESULTS

Forty-six patients received 3F-PCC, and 18 received 4F-PCC. Baseline INR was similar for 3F-PCC and 4F-PCC patients (3.1 ± 2.3 vs 3.4 ± 3.7, P = .520). The initial PCC dose was 29 ± 9 U/kg for 3F-PCC and 26 ± 6 U/kg for 4F-PCC (P = .102). The follow-up INR was 1.6 ± 0.6 for 3F-PCC and 1.3 ± 0.2 for 4F-PCC (P = .001). Successful reversal rates in patients were 83% for 4F-PCC and 50% for 3F-PCC (P = .022). Thromboembolic events were observed in 15% of patients with 3F-PCC vs 0% with 4F-PCC (P = .177). Cost-effectiveness favored 4F-PCC ($5382 vs $3797).

CONCLUSIONS

Three-factor PCC and 4F-PCC were both safe in correcting INR, but 4F-PCC was more effective, leading to better cost-effectiveness. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients and institutions.

Anticoagulation Therapy in Traumatic Brain Injury

BACKGROUND

Optimal anticoagulation therapy (AT) in patients with traumatic brain injury (TBI) is a challenging task and proper management is strongly correlated with clinical outcomes. Only limited data are available on AT after TBI and practical decision making is based on the opinion of experts. This review sought to critically assess different therapeutic options using AT and antiplatelet agents in the perioperative period after TBI.

METHODS

A comprehensive review of the literature was performed to summarize relevant data on AT in patients with TBI.

RESULTS

Patients with preinjury AT with TBI require emergent neurosurgical treatment and they are also at high risk of developing thromboembolic complications or hematoma expansion. New oral anticoagulants offer a lower incidence of intracranial hemorrhage compared with warfarin. The rate of intracranial hemorrhage during new oral anticoagulants or heparin therapy is significantly lower than that with vitamin K antagonists.