The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy

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

PURPOSE

The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings.

METHODS

This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis.

RESULTS

A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant.

CONCLUSION

According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.

Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis

The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.

Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort

BACKGROUND

Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED).

OBJECTIVE

This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI.

METHODS

A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED.

RESULTS

Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients.

CONCLUSIONS

Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.

Evaluation of Laboratory Variables Related to Diffuse Axonal Injury: A Cross-Sectional Study

Background: Diffuse axonal injury (DAI) is an injury that occurs after the onset of traumatic brain injury (TBI), leading to many problems for patients and imposing high costs on the treatment system. Objectives: This study was conducted to investigate the status of laboratory variables in patients with DAI. Methods: This cross-sectional study included 140 patients. Data collection tools were a demographic profile form and magnetic resonance imaging (MRI). Laboratory tests, including glucose, LDL-C, HDL-C, total cholesterol, triglycerides, Hb, HCT, PT, PTT, INR, BUN, creatinine, and CRP were evaluated. Also, specialized devices were used to study the laboratory and radiology variables. Results: Most (61.5%) of the patients were male, 47.1% had a non-governmental occupation, and 55.7% were less than 30 years old. Also, in 87.9% of cases, traffic accidents were the cause of DAI and in 65% of patients, the Glasgow Coma Scale (GCS) was less than 7. In all the laboratory variables differences were observed between the experimental and the control groups. Conclusions: The laboratory variables in patients with DAI had a statistically significant difference compared to the case group, which indicates the negative effect of DAI on laboratory variables. Further studies are required to confirm our results.

Delayed intracranial hemorrhage of patients with mild traumatic brain injury under antithrombotics on routine repeat CT scan: a systematic review and meta-analysis

In childhood, traumatic brain injury (TBI) poses the unique challenges of an injury to a developing brain and the dynamic pattern of recovery over time, inflicted TBI and its medicolegal ramifications. The mechanisms of injury vary with age, as do the mechanisms that lead to the primary brain injury. As it is common, and is the leading cause of death and disability in the USA and Canada, prevention is the key, and we may need increased legislation to facilitate this. Despite its prevalence, there is an almost urgent need for research to help guide the optimal management and improve outcomes.

Indeed, contrary to common belief, children with severe TBI have a worse outcome and many of the consequences present in teenage years or later. The treatment needs, therefore, to be multifaceted and starts at the scene of the injury and extends into the home and school. In order to do this, the care needs to be multidisciplinary from specialists with a specific interest in TBI and to involve the family, and will often span many decades.

Increased relative risk of delayed hemorrhage in patients taking anticoagulant/antiplatelet medications with concurrent aspirin therapy: implications for clinical practice based on 3-year retrospective analysis in a large health system

PURPOSE

The incidence of delayed posttraumatic intracranial hemorrhage (DH) in patients on anticoagulant (AC) and antiplatelet (AP) medications, especially with concurrent aspirin therapy, is not well established, with studies reporting disparate results with between 1-10% risk of DH and 0-3% mortality. The purpose of this 3-year retrospective study is to evaluate the true risk of DH in patients on AP/AC medications with or without concurrent aspirin therapy.

METHODS

One thousand forty-six patients taking AP and AC medications presenting to network emergency departments with head trauma who had repeat CT to evaluate for DH were included in the study. Repeat examinations were typically performed within 24 h (average follow-up time was 21 h and 99% were within 3 days). Mean time to DH was 20 h. All positive studies were reviewed by two board-certified neuroradiologists. Patients were excluded from the study if hemorrhage was retrospectively identified on the initial examination. Cases were reclassified as negative if hemorrhage on the follow-up examination was thought to be not present or artifactual. Cases were considered positive if the initial examination was negative and the follow-up examination demonstrated new hemorrhage.

RESULTS

Overall, there was 1.91% incidence (20 patients) of DH and 0.3% overall mortality (3 patients). The group of patients taking warfarin or AP agents demonstrated a significantly higher rate of DH (3.2% compared to 0.9%) and higher mortality (0.9% compared to 0.0%) compared to the DOAC group (p < 0.01). The risk of DH in patients taking AC or AP agents with aspirin (13/20 cases) was significantly higher (RR 3.8, p < 0.01) than that of patients taking AC or AP alone (7/20 cases).

CONCLUSION

The risk of DH was significantly higher in patients taking aspirin in addition to AC/AP medications. Repeat imaging should be obtained for trauma patients taking AC/AP agents with concurrent aspirin. The rate of DH was also significantly higher in patients taking warfarin or AP agents when compared to patients taking DOACs. Repeat examination should be strongly considered on patients taking warfarin or AP agents without aspirin. Given the relatively low risk of DH in patients taking DOACs alone, repeat imaging could be reserved for patients with external signs of trauma or dangerous mechanism of injury.

The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs)

BACKGROUND

New direct oral anticoagulants (DOACs) are commonly used in the management of atrial fibrillation and VTE. Currently, there is no strong evidence to support the current practice of routinely repeating computed tomography (CT) head in anticoagulated patients within 24 hours after their first negative CT scan to assess for new and delayed intracranial hemorrhage (ICH). Our hypothesis is that the vast majority will not have new CT scan findings of ICH and those who do would not require any further intervention.

METHODS

This is retrospective cohort study. IRB approval was obtained. Subjects included adults age ≥ 18 taking DOACs who presented to our level III trauma center with confirmed or suspected blunt head trauma between August 2013 and October 2019 and received at least one head CT scans.

RESULTS

498 Patient encounters met inclusion criteria. Only 19 patients (3.8%) had positive traumatic ICH on the initial CT head. Those had a higher ISS. 420 out of 479 initial negative CT encounters received a second CT head. Only 2 (0.5%) had delayed positive second CT scan for ICH. 95%CI [0.06%, 1.7%] Patients who developed a new ICH on the second CT head after an initial negative CT scan had a lower Glasgow Coma Scale (GCS) on presentation and a higher ISS. None of those patients required neurosurgical intervention CONCLUSION: Our data suggests that the risk of developing a new or delayed traumatic ICH for patients on DOAC on a second CT head within 24 hours following an initial negative CT is very low and when present did not require neurosurgical intervention and thus does not support routinely obtaining a repeat CT head within 24 hours after a negative initial CT scan. Patients presenting with lower GCS and higher ISS had a higher chance of having a delayed ICH.

Incidence of delayed bleeding in patients on antiplatelet therapy after mild traumatic brain injury: a systematic review and meta-analysis

Background

The scientific evidence regarding the risk of delayed intracranial bleeding (DB) after mild traumatic brain injury (MTBI) in patients administered an antiplatelet agent (APA) is scant and incomplete. In addition, no consensus exists on the utility of a routine repeated head computed tomography (CT) scan in these patients.

Objective

The aim of this study was to evaluate the risk of DB after MTBI in patients administered an APA.

Methods

A systematic review and meta-analysis of prospective and retrospective observational studies enrolling adult patients with MTBI administered an APA and who had a second CT scan performed or a clinical follow-up to detect any DB after a first negative head CT scan were conducted. The primary outcome was the risk of DB in MTBI patients administered an APA. The secondary outcome was the risk of clinically relevant DB (defined as any DB leading to neurosurgical intervention or death).

Results

Sixteen studies comprising 2930 patients were included in this meta-analysis. The pooled absolute risk for DB was 0.77% (95% CI 0.23–1.52%), ranging from 0 to 4%, with substantial heterogeneity (I² = 61%). The pooled incidence of clinically relevant DB was 0.18%. The subgroup of patients on dual antiplatelet therapy (DAPT) had an increased DB risk, compared to the acetylsalicylic acid (ASA)-only patients (2.64% vs. 0.22%; p = 0.04).

Conclusion

Our systematic review showed a very low risk of DB in MTBI patients on antiplatelet therapy. We believe that such a low rate of DB could not justify routine repeated CT scans in MTBI patients administered a single APA. We speculate that in the case of clinically stable patients, a repeated head CT scan could be useful for select high-risk patients and for patients on DAPT before discharge.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00936-9.

Management of Mild Brain Trauma in the Elderly: Literature Review

Purpose

The world population is aging. As direct consequence, geriatric trauma is increasing both in absolute number and in the proportion of annual admissions causing a challenge for the health-care system worldwide. The aim of this review is to delineate the specific and practice rules for the management of mild brain trauma in the elderly.

Methods

Systematic review of the last 15 years literature on mild traumatic brain injury (nTBI) in elderly patients.

Results

A total of 68 articles met all eligibility criteria and were selected for the systematic review. We collected 29% high-quality studies and 71% low-quality studies.

Conclusion

Clinical advices for a comprehensive management are provided. Current outcome data from mTBIs in the elderly show a condition that cannot be sustained in the future by families, society, and health-care systems. There is a strong need for more research on geriatric mild brain trauma addressed to prevent falls, to reduce the impact of polypharmacy, and to define specific management strategies.

Delayed intracranial hemorrhage after trauma

Introduction: Delayed Intracranial Hemorrhage (D-ICH), defined as finding of ICH on subsequent imaging after a normal computed tomography of the brain (CTB), is a feared complication after head trauma. The aim of this study was to determine the incidence and severity of D-ICH.Methods: This retrospective cohort study included patients that presented directly from the scene of injury to an adult major trauma center from Jan 2013 to Dec 2018.Results: There were 6536 patients who had an initial normal CTB and 23 (0.3%; 95%CI: 0.20-0.47) had D-ICH. There were 653 patients who had a repeat CTB (incidence of D-ICH 3.5%; 95%CI: 2.2-5.2). There was no significant association of D-ICH with age>65 years (OR 1.33; 95%CI: 0.54-3.29), presenting GCS <15 (OR 1.21; 95% CI: 0.52-2.80) and anti-platelet medications (OR 0.68; 95%CI: 0.26-1.74). Exposure to anti-coagulant medications was associated with lower odds of D-ICH (OR 0.23; 95%CI: 0.05-0.99). All cases of D-ICH were diffuse injury type II lesions on the Marshall classification. There were no cases that underwent neurosurgical intervention and no deaths were attributed to D-ICH.Conclusions: These results question observation of patients with head injury in hospital after a normal CTB for the sole purpose of excluding D-ICH.

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

Background: Delayed intracranial hemorrhage can occur up to several weeks after head trauma and was reported more frequently in patients with antithrombotic therapy. Due to the risk of delayed intracranial hemorrhage, some hospitals follow extensive observation and cranial computed tomography (CT) protocols for patients with head trauma, while others discharge asymptomatic patients after negative CT. Methods: We retrospectively analyzed data on patients with head trauma and antithrombotic therapy without pathologies on their initial CT. During the observation period, we followed a protocol of routine repeat CT before discharge for patients using vitamin K antagonists, clopidogrel or direct oral anticoagulants. Results: 793 patients fulfilled the inclusion criteria. Acetylsalicylic acid (ASA) was the most common antithrombotic therapy (46.4%), followed by vitamin K antagonists (VKA) (32.2%) and Clopidogrel (10.8%). We observed 11 delayed hemorrhages (1.2%) in total. The group of 390 patients receiving routine repeat CT showed nine delayed hemorrhages (2.3%). VKA were used in 6 of these 11 patients. One patient needed an urgent decompressive craniectomy while the other patients were discharged after an extended observation period. The patient requiring surgical intervention due to delayed hemorrhage showed neurological deterioration during the observation period. Conclusions: Routine repeat CT scans without neurological deterioration are not necessary if patients are observed in a clinical setting. Patients using ASA as single antithrombotic therapy do not require in-hospital observation after a negative CT scan.

Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis

BACKGROUND

There is debate regarding routine repeat head computed tomography (CT) in blunt trauma patients on a pre-injury antithrombotic when the initial CT is negative for intracranial hemorrhage (ICH).

DATA SOURCES

Retrospective chart review and systematic literature review with meta-analysis.

CONCLUSIONS

In the chart review, 32.1% did not have a repeat head CT and 67.9% did. The delayed ICH incidence between those with and without a repeat head CT was similar (1.7% vs 0, p = .3101). The current study was combined with the identified 24 studies. Delayed ICH with or without routine repeat CT was similar between antiplatelet and anticoagulant categories (1.4% vs. 1.3%, p = .5322). Delayed ICH was lower for patients without routine repeat CT compared to those with routine repeat CT (0.8% vs 1.7%, p = .0008). For this patient population, repeat scans should be discretionary. Routine repeat CT may identify a larger proportion of minor delayed ICH.

C1-C2 fractures in asymptomatic elderly patients with minor head trauma: evaluation with a dedicated head CT protocol

Objective

To evaluate the frequency and types of upper cervical spine injuries in asymptomatic elderly patients undergoing computed tomography (CT) for the investigation of minor head trauma.

Materials and Methods

This was a prospective study of 2613 asymptomatic elderly patients with minor head trauma seen between January 2015 and December 2016. We adopted a dedicated head CT protocol that included the C1-C2 region.

Results

Of the 2613 patients analyzed, 33 (1.26%) had upper cervical spine injuries, corresponding to 8.37% of the 394 patients with trauma-related findings. Of those 33 patients, 6 had C1 fractures and 27 had C2 fractures. The use of 16- and 128-slice scanners increased the CT dose by 25.0% and 23.7%, respectively.

Conclusion

Inclusion of the C1-C2 region in head CT scans allowed us to identify upper cervical spine injuries in 1.26% of asymptomatic elderly patients with minor head trauma. The protocol evaluated helps detect potentially life-threatening injuries and could be adopted for routine use in elderly individuals with minor head trauma.

Worsening head bleeds in elderly blunt head trauma patients taking antithrombotics: Delayed CT head fails to change management

BACKGROUND

Most elderly trauma patients suffer blunt head injury and many utilize antithrombotic (AT) medications. The utility of delayed CT-head (D-CTH) in neurologically intact elderly patients using AT who have an intracranial hemorrhage (ICH) on presentation is unknown. We hypothesized that D-CTH would not alter clinical management and aimed to evaluate the role of D-CTH in this population.

METHODS

A retrospective cohort study was performed. Patients ≥65 years sustaining blunt head injuries from January 2010 to July 2017 were identified using our level 1 trauma center database. AT-patients presenting with ICH who underwent D-CTH were included. Patients with worsened ICH were compared to those with stable to improved ICH on D-CTH. AT-patients were compared to a cohort of non-AT patients. Fisher's Exact and Mann-Whitney U tests were utilized and a power analysis conducted.

RESULTS

137 A T and 34 non-AT patients were identified. There was no difference in hemorrhage progression or appearance of new ICH. No patient had a change in management from D-CTH in either cohort. AT-patients were slightly older (p < 0.001), but cohorts were otherwise similar. 50 AT-patients with worsened ICH were compared to 87 with stable ICH. There was no difference in cohort demographics. Hemorrhage progression did not vary with type of AT used but did increase if multiple types of synchronous ICH were present (p < 0.001).

CONCLUSIONS

Our data supports abstaining from routine D-CTH of elderly ICH patients with an intact neurologic examination who are utilizing aspirin, clopidogrel or warfarin. Conclusions cannot be drawn regarding new oral anticoagulants (NOACs) given low enrollment. Further multicenter study is required to provide adequate power and detect small levels of management change.

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

BACKGROUND

Falls are a common cause of hospitalization, morbidity, and mortality among the elderly in the United States. Evidence-based imaging recommendations for evaluation of delayed intracranial hemorrhage (DICH) are not generally agreed upon. The purpose of this project was to evaluate the incidence of DICH detected by head computer tomography (CT) among an elderly population on pre-injury anticoagulant or antiplatelet (ACAP) therapy.

METHODS

Data from a Level 1 Trauma Center trauma registry was used to assess the incidence of DICH in an elderly population of patients (≥65 years) who sustained a minor fall while on pre-injury ACAP medications. Counts and percentages are reported.

RESULTS

Data on 1076 elderly trauma patients were downloaded, of which 838 sustained a minor fall and 513 were found to be using a pre-injury ACAP medication. One patient (0.46%) with a DICH was identified out of 218 patients who received a routine repeat head CT. Aspirin and warfarin were the most common pre-injury ACAP medications and 19.27% (42/218) of patients were found to be using multiple ACAP medications.

CONCLUSIONS

Universal screening protocols promote immediate-term patient safety, but do so at a great expense with respect to health expenditures and increased radiation exposure. This analysis highlights the need for an effective risk assessment tool for DICH that would reduce the burden of unnecessary screenings while still identifying life-threatening intracranial hemorrhages in affected patients.