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Menditto VG, Moretti M, Babini L, Mattioli A, Giuliani AR, Fratini M, Pallua FY, Andreoli E, Nitti C, Contucci S, Gabrielli A, Rocchi MBL, Pomponio G. Minor head injury in anticoagulated patients: performance of biomarkers S100B, NSE, GFAP, UCH-L1 and Alinity TBI in the detection of intracranial injury. A prospective observational study. Clin Chem Lab Med 2024; 62:1376-1382. [PMID: 38206121 DOI: 10.1515/cclm-2023-1169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVES Data in literature indicate that in patients suffering a minor head injury (MHI), biomarkers serum levels could be effective to predict the absence of intracranial injury (ICI) on head CT scan. Use of these biomarkers in case of patients taking oral anticoagulants who experience MHI is very limited. We investigated biomarkers as predictors of ICI in anticoagulated patients managed in an ED. METHODS We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The outcome was delayed ICI (dICI), defined as ICI on the second CT scan after a first negative CT scan. We assessed the sensitivity (SE), specificity (SP), negative predictive value (NNV) and positive predictive value (PPV) of the biomarkers S100B, NSE, GFAP, UCH-L1 and Alinity TBI in order to identify dICI. RESULTS Our study population was of 234 patients with a negative first CT scan who underwent a second CT scan. The rate of dICI was 4.7 %. The NPV for the detection of dICI were respectively (IC 95 %): S100B 92.7 % (86.0-96.8 %,); ubiquitin C-terminal hydrolase-L1 (UCH-L1) 91.8 % (83.8-96.6 %); glial fibrillary protein (GFP) 100 % (83.2-100 %); TBI 100 % (66.4-100 %). The AUC for the detection of dICI was 0.407 for S100B, 0.563 for neuron-specific enolase (NSE), 0.510 for UCH-L1 and 0.720 for glial fibrillary acidic protein (GFAP), respectively. CONCLUSIONS The NPV of the analyzed biomarkers were high and they potentially could limit the number of head CT scan for detecting dICI in anticoagulated patients suffering MHI. GFAP and Alinity TBI seem to be effective to rule out a dCI, but future trials are needed.
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Affiliation(s)
- Vincenzo G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Marco Moretti
- Medicina di Laboratorio, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Lucia Babini
- Medicina di Laboratorio, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Annalisa Mattioli
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Andres Ramon Giuliani
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Marina Fratini
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Fabienne Yvonne Pallua
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Elisa Andreoli
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Cinzia Nitti
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Susanna Contucci
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - Armando Gabrielli
- Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, Ancona, Italy
| | | | - Giovanni Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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Karamian A, Seifi A, Karamian A, Lucke-Wold B. Incidence of intracranial bleeding in mild traumatic brain injury patients taking oral anticoagulants: a systematic review and meta-analysis. J Neurol 2024:10.1007/s00415-024-12424-y. [PMID: 38755424 DOI: 10.1007/s00415-024-12424-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) is one of the leading causes of disability and death worldwide. Most TBI cases occur in older people, because they are at a higher risk of accidental falling. As the population ages, the use of anticoagulants is increasing. Some serious complications of TBI, such as intracranial hemorrhage (ICH), may occur even in mild cases. According to the current guidelines regarding managing mild TBI patients, a CT head scan is recommended for all patients receiving anticoagulation. We aim to assess the incidence of ICH in patients with mild TBI taking oral anticoagulants. METHODS Our systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The protocol was registered in PROSPERO (CRD42024503086). Twenty-eight studies evaluating patients with a mild TBI from ten countries with a total sample size of 11,172, 5671 on DOACs, and 5501 on VKAs were included in our meta-analysis. RESULTS The random-effects overall incidence of ICH among oral anticoagulated patients with mild TBI was calculated to be 9.4% [95% CI 7.2-12.1%, I2 = 89%]. The rates of immediate ICH for patients taking DOACs and VKAs were 6.4% and 10.5%, respectively. The overall rate of immediate ICH in anticoagulated mild TBI patients was 8.5% [95% CI 6.6-10.9%], with a high heterogeneity between studies (I2 = 88%). Furthermore, the rates of delayed ICH in patients with mild TBI taking DOACs and VKAs were 1.6% and 1.9%, respectively. The overall incidence of delayed ICH among oral anticoagulated mild TBI patients was 1.7% [95% CI 1-2.8%, I2 = 79%]. The overall rate of ICH among mild TBI patients taking DOAC was calculated to be 7.3% [95% CI 5.2-10.3%], with significant heterogeneity between studies (I2 = 79%). However, the overall ICH rate is higher in patients who take only VKAs 11.3% [95% CI 8.6-14.7%, I2 = 83%]. Patients on DOACs were at lower risk of ICH after mild TBI compared to patients on VKAs (OR = 0.64, 95% CI 0.48-0.86, p < 0.01, I2 = 28%). CONCLUSION Our meta-analysis confirms the need for performing brain CT scan in patients with mild TBI patients who receive oral anticoagulants before injury. Due to limited data, further multi-center, prospective studies are warranted to confirm the true incidence of traumatic ICH in patients on anticoagulants.
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Affiliation(s)
- Armin Karamian
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Seifi
- Department of Neurosurgery, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Amin Karamian
- Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
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Menditto VG, Moretti M, Babini L, Sampaolesi M, Buzzo M, Montillo L, Raponi A, Riccomi F, Marcosignori M, Rocchi M, Pomponio G. Minor head injury in anticoagulated patients: Outcomes and analysis of clinical predictors. A prospective study. Am J Emerg Med 2024; 76:105-110. [PMID: 38056055 DOI: 10.1016/j.ajem.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND The optimal management of patients taking oral anticoagulants who experience minor head injury (MHI) is unclear. The availability of validated protocols and reliable predictors of prognosis would be of great benefit. We investigated clinical factors as predictors of clinical outcomes and intracranial injury (ICI). METHODS We conducted a single-cohort, prospective, observational study in an ED. Our structured clinical pathway included a first head CT scan, 24 h observation and a second CT scan. The primary outcome was the occurrence of MHI-related death or re-admission to ED at day +30. The secondary outcome was the rate of delayed ICI (dICI), defined as second positive CT scan after a first negative CT scan. We assessed some clinical predictors derived from guidelines and clinical prediction rules as potential risk factors for the outcomes. RESULTS 450 patients with a negative first CT scan who underwent a second CT scan composed our 'study population'. The rate of the primary outcome was 4%. The rate of the secondary outcome was 4.7%. Upon univariate and multivariate analysis no statistically significant predictors for the outcomes were found. CONCLUSIONS Previous retrospective studies showed a lot of negative predictive factors for anticoagulated patients suffering a minor head injury. In our prospective study no clinical factors emerged as predictors of poor clinical outcomes and dICI. So, even if we confirmed a low rate of adverse outcomes, the best management of these patients in ED remains not so clear and future trials are needed.
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Affiliation(s)
- V G Menditto
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy.
| | - M Moretti
- Medicina di Laboratorio, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - L Babini
- Medicina di Laboratorio, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - M Sampaolesi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - M Buzzo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - L Montillo
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - A Raponi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - F Riccomi
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - M Marcosignori
- Emergency and Internal Medicine Department, Azienda Ospedaliero Universitaria delle Marche, Ancona, Ancona, Italy
| | - M Rocchi
- Statistica Medica, Dipartimento di Scienze Biomolecolari, Università di Urbino, Urbino, Italy
| | - G Pomponio
- Clinica Medica, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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Park N, Barbieri G, Turcato G, Cipriano A, Zaboli A, Giampaoli S, Bonora A, Ricci G, Santini M, Ghiadoni L. Multi-centric study for development and validation of a CT head rule for mild traumatic brain injury in direct oral anticoagulants: the HERO-M nomogram. BMC Emerg Med 2023; 23:122. [PMID: 37840139 PMCID: PMC10578033 DOI: 10.1186/s12873-023-00884-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Nomograms are easy-to-handle clinical tools which can help in estimating the risk of adverse outcome in certain population. This multi-center study aims to create and validate a simple and usable clinical prediction nomogram for individual risk of post-traumatic Intracranial Hemorrhage (ICH) after Mild Traumatic Brain Injury (MTBI) in patients treated with Direct Oral Anticoagulants (DOACs). METHODS From January 1, 2016 to December 31, 2019, all patients on DOACs evaluated for an MTBI in five Italian Emergency Departments were enrolled. A training set to develop the nomogram and a test set for validation were identified. The predictive ability of the nomogram was assessed using AUROC, calibration plot, and decision curve analysis. RESULTS Of the 1425 patients in DOACs in the study cohort, 934 (65.5%) were included in the training set and 491 (34.5%) in the test set. Overall, the rate of post-traumatic ICH was 6.9% (7.0% training and 6.9% test set). In a multivariate analysis, major trauma dynamic (OR: 2.73, p = 0.016), post-traumatic loss of consciousness (OR: 3.78, p = 0.001), post-traumatic amnesia (OR: 4.15, p < 0.001), GCS < 15 (OR: 3.00, p < 0.001), visible trauma above the clavicles (OR: 3. 44, p < 0.001), a post-traumatic headache (OR: 2.71, p = 0.032), a previous history of neurosurgery (OR: 7.40, p < 0.001), and post-traumatic vomiting (OR: 3.94, p = 0.008) were independent risk factors for ICH. The nomogram demonstrated a good ability to predict the risk of ICH (AUROC: 0.803; CI95% 0.721-0.884), and its clinical application showed a net clinical benefit always superior to performing CT on all patients. CONCLUSION The Hemorrhage Estimate Risk in Oral anticoagulation for Mild head trauma (HERO-M) nomogram was able to predict post-traumatic ICH and can be easily applied in the Emergency Department (ED).
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Affiliation(s)
- Naria Park
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Greta Barbieri
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy.
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Via Savi, Pisa, 10 - 56126, Italy.
| | | | | | - Arian Zaboli
- Emergency Department, Hospital of Merano, Merano, Italy
| | - Sara Giampaoli
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Antonio Bonora
- Emergency Department, University of Verona, Verona, Italy
| | - Giorgio Ricci
- Emergency Department, University of Verona, Verona, Italy
| | - Massimo Santini
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Cipriano A, Turcato G, Park N, Zaboli A, Barbieri G, Riccardi A, Santini M, Lerza R, Bonora A, Ghiadoni L. Minimal is not minor also in patients with mild traumatic brain injury on oral direct anticoagulant therapy. Intern Emerg Med 2023; 18:1533-1541. [PMID: 36869261 DOI: 10.1007/s11739-023-03244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/21/2023] [Indexed: 03/05/2023]
Abstract
Currently, all patients, regardless of the type of head injury, should undergo a head computerized tomography (CT) if on oral anticoagulant therapy. The aim of the study was to assess the different incidences of intracranial hemorrhage (ICH) between patients with minor head injury (mHI) and patients with mild traumatic brain injury (MTBI) and whether there were differences in the risk of death at 30 days as a result of trauma or neurosurgery. A retrospective multicenter observational study was conducted from January 1, 2016, to February 1, 2020. All patients on DOACs therapy who suffered head trauma and underwent a head CT were extracted from the computerized databases. Patients were divided into two groups MTBI vs mHI all in DOACs treatment. Whether a difference in the incidence of post-traumatic ICH was present was investigated, and pre- and post-traumatic risk factors were compared between the two groups to assess the possible association with ICH risk by propensity score matching. 1425 with an MTBI in DOACs were enrolled. Of these, 80.1% (1141/1425) had an mHI and 19.9% (284/1425) had an MTBI. Of these, 16.5% (47/284) patients with MTBI and 3.3% (38/1141) with mHI reported post-traumatic ICH. After propensity score matching, ICH was consistently found to be more associated with patients with MTBI than with mHI (12.5% vs 5.4%, p = 0.027). Risk factors associated with immediate ICH in mHI patients were high energy impact, previous neurosurgery, trauma above the clavicles, post-traumatic vomiting and headache. Patients on MTBI (5.4%) were found to be more associated with ICH than those with mHI (0.0%, p = 0.002). also when the need for neurosurgery or death within 30 days were considered. Patients on DOACs with mHI have a lower risk of presenting with post-traumatic ICH than patients with MTBI. Furthermore, patients with mHI have a lower risk of death or neurosurgery than patients with MTBI, despite the presence of ICH.
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Affiliation(s)
- Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Gianni Turcato
- Intermediate Care Unit, Department of Internal Medicine, Hospital Alto Vicentino, Santorso, Italy
| | - Naria Park
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy.
| | - Greta Barbieri
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Emergency Medicine Department, University of Pisa, Pisa, Italy
| | - Alessandro Riccardi
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Massimo Santini
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Roberto Lerza
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Antonio Bonora
- Emergency Department, University of Verona, Verona, Italy
| | - Lorenzo Ghiadoni
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
- Emergency Medicine Department, University of Pisa, Pisa, Italy
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Valente JH, Anderson JD, Paolo WF, Sarmiento K, Tomaszewski CA, Haukoos JS, Diercks DB, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023). Ann Emerg Med 2023; 81:e63-e105. [PMID: 37085214 PMCID: PMC10617828 DOI: 10.1016/j.annemergmed.2023.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.
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Limited benefit of systematic head CT for mild traumatic brain injury in patients under antithrombotic therapy. J Neuroradiol 2023; 50:30-35. [PMID: 33636220 DOI: 10.1016/j.neurad.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Mild traumatic brain injury (mTBI) in patients on antiplatelet (AP), anticoagulant (AC) or direct oral anticoagulant (DOAC) medication has become a systematic indication for head CT. However, the over-risk and impact of the intracranial hemorrhages (IH) detected with CT in this population remain unclear and need to be assessed. MATERIALS AND METHODS We prospectively assessed head CTs performed in adults taking AP/AC/DOAC referred after a mTBI to our Emergency Departments between September 2016 and January 2018. Frequency, type and severity of IH were described and frequency was analyzed as a function of treatment. RESULTS 840 patients were prospectively included. 58.9% were treated with AP, 23.7% with AC, 11.7% with DOAC and 5.7% with a combination of antithrombotic agents. The rate of IH detected with head CT was 5.8% (n...=...49), of which 81.6% (n...=...40) and 18.4% (n...=...9) with minor and intermediate severity respectively. No patient required surgical care and no death occurred. No statistically significant difference was found in treatment distribution between patients with or without IH (p...=...0.98). Among the patients who discontinued their antithrombotic treatment after mTBI, three experienced thrombotic events during the hospitalization. CONCLUSIONS Our results showed a low frequency and severity of IH in mTBI patients indifferently treated with AP, AC or DOAC, without secondary neurological deterioration, death or need of surgical care. Our study suggests the limited benefit of systematic CT head scan as a standard practice for the management of mTBI patients under antithrombotic therapy.
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Turcato G, Zaboli A, Bonora A, Ricci G, Zannoni M, Maccagnani A, Zorzi E, Pfeifer N, Brigo F. 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. J Emerg Med 2023; 64:1-13. [PMID: 36658008 DOI: 10.1016/j.jemermed.2022.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/25/2022] [Accepted: 09/04/2022] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Antonio Bonora
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giorgio Ricci
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Massimo Zannoni
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Antonio Maccagnani
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Elisabetta Zorzi
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
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ÇATAL Y, GÜNALP M, GENÇ S, OĞUZ AB, KOCA A, POLAT O. Do We Need to Repeat the Initially Normal Head Computerized Tomography for Patients with Mild Head Trauma Using Anticoagulant and/or Antiplatelet Therapy? KONURALP TIP DERGISI 2022. [DOI: 10.18521/ktd.1167329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objective: Patients using anticoagulant and/or antiplatelet (AC/AP) medications are at an increased risk of intracranial hemorrhage (ICH) subsequent to head trauma and current guidelines recommend a head computed tomography (CT) scan for these patients. There is a lack of consensus about management recommendations for mild head trauma patients on AC/AP treatment who had an initially normal head CT. The aim of this study was to determine the rate of delayed ICH after a 24-hour observation in patients with mild head trauma using AC/AP who had an initially normal head CT.
Method: Patients aged 18 and older, using AC/AP drugs with mild head trauma were included prospectively. Patients underwent head CT for suspected bleeding. A repeat CT scan was performed after a 24-hours observation period for the patients who had an initially normal head CT for detecting delayed intracranial hemorrhage.
Result: A total of 101 patients were included and, 57.4% (n=58) of the patients were female. Delayed ICH was detected in 2.9% (n=3) of the patients after a 24-hour observation. None of the patients with delayed ICH needed surgical treatment or further intervention. Delayed ICH was found in patients who used acetylsalicylic acid (n=1), dabigatran (n=1), and apixaban (n=1).
Conclusion: In patients with mild head trauma using AC/AP, delayed intracranial hemorrhage is rare and may be clinically insignificant. A repeat CT scanning after 24-hour observation may not be necessary for patients with mild head trauma using AC/AP therapy who had initially normal head CT.
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Affiliation(s)
- Yaşar ÇATAL
- Kayseri State Hospital, Department of Emergency Medicine
| | - Müge GÜNALP
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Sinan GENÇ
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Ahmet Burak OĞUZ
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Ayça KOCA
- Ankara University School of Medicine, Department of Emergency Medicine
| | - Onur POLAT
- Ankara University School of Medicine, Department of Emergency Medicine
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Park N, Turcato G, Zaboli A, Santini M, Cipriano A. The state of the art of the management of anticoagulated patients with mild traumatic brain injury in the Emergency Department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The effects of Oral Anticoagulation Therapy (OAT) in older patients who suffered a mild Traumatic Brain Injury (mTBI) are widely debated but still strong guidelines are lacking and clinical approaches and management are sometimes heterogeneous. Different predictors of adverse outcomes were identified in the literature but their use in the decision-making process is unclear. Moreover, there is no consensus on the appropriate length of stay in the Observation Unit nor on the continuation of OAT, even if the diagnosis of life-threatening delayed post-traumatic Intracranial Hemorrhage is rare. The recurrence of a control CT scan is often needless. This review aims to summarize recent scientific literature focusing on patients with mTBI taking OAT and to identify crucial questions on the topic to suggest a best clinical practice.
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Turcato G, Cipriano A, Park N, Zaboli A, Ricci G, Riccardi A, Barbieri G, Gianpaoli S, Guiddo G, Santini M, Pfeifer N, Bonora A, Paolillo C, Lerza R, Ghiadoni L. "Decision tree analysis for assessing the risk of post-traumatic haemorrhage after mild traumatic brain injury in patients on oral anticoagulant therapy". BMC Emerg Med 2022; 22:47. [PMID: 35331163 PMCID: PMC8944105 DOI: 10.1186/s12873-022-00610-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI. METHODS Three thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient's risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables. RESULTS ICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH. CONCLUSIONS The machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy.
| | - Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Naria Park
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy
| | - Giorgio Ricci
- Emergency Department, University of Verona, Verona, Italy.,Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
| | - Alessandro Riccardi
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Greta Barbieri
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Sara Gianpaoli
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Grazia Guiddo
- Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Massimo Santini
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Via Rossini 5, 39012, Merano, Italy
| | - Antonio Bonora
- Emergency Department, University of Verona, Verona, Italy
| | - Ciro Paolillo
- Emergency Department, University of Verona, Verona, Italy.,Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy
| | - Roberto Lerza
- Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy.,Emergency Department, Hospital of San Paolo (ASL N°2 Savonese), Savona, Italy
| | - Lorenzo Ghiadoni
- Academy of Emergency Medicine and Care (AcEMC), Pavia, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Santing J, Lee YX, van der Naalt J, van den Brand C, Jellema K. Mild traumatic brain injury in elderly patients receiving direct oral anticoagulants: A systematic review and meta-analysis. J Neurotrauma 2022; 39:458-472. [DOI: 10.1089/neu.2021.0435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Juliette Santing
- Medisch Centrum Haaglanden Westeinde, 2901, Neurology, Lijnbaan 12, Den Haag, Netherlands, 2501 CK, ,
| | - Ying Xing Lee
- Medisch Centrum Haaglanden Westeinde, 2901, Neurology, Den Haag, Zuid-Holland, Netherlands
| | | | - Crispijn van den Brand
- Haaglanden Medical Center, Department of Emergency Medicine, Lijnbaan 32, The Hague, Zuid-Holland, Netherlands, 2512VA
| | - Korné Jellema
- Medisch Centrum Haaglanden, 2901, Den Haag, Zuid-Holland, Netherlands
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Turcato G, Zaboli A, Pfeifer N, Maccagnani A, Tenci A, Giudiceandrea A, Zannoni M, Ricci G, Bonora A, Brigo F. Decision tree analysis to predict the risk of intracranial haemorrhage after mild traumatic brain injury in patients taking DOACs. Am J Emerg Med 2021; 50:388-393. [PMID: 34478944 DOI: 10.1016/j.ajem.2021.08.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Although the preliminary evidence seems to confirm a lower incidence of post-traumatic bleeding in patients treated with direct oral anticoagulants (DOACs) compared to those on vitamin K antagonists (VKAs), the recommended management of mild traumatic brain injury (MTBI) in patients on DOACs is the same as those on the older VKAs, risking excessive use of CT in the emergency department (ED). AIM To determine which easily identifiable clinical risk factors at the first medical evaluation in the ED may indicate an increased risk of post-traumatic intracranial haemorrhage (ICH) in patients on DOACs with MTBI. METHODS Patients on DOACs who were evaluated in the ED for an MTBI from 2016 to 2020 at four centres in Northern Italy were considered. A decision tree analysis using the chi-square automatic interaction detection (CHAID) method was conducted to assess the risk of post-traumatic ICH after an MTBI. Known pre- and post-traumatic clinical risk factors that are easily identifiable at the first medical evaluation in the ED were used as input predictor variables. RESULTS Among the 1146 patients on DOACs in this study, post-traumatic ICH was present in 6.5% (75/1146). Decision tree analysis using the CHAID method found post-traumatic TLOC, post-traumatic amnesia, major trauma dynamic, previous neurosurgery and evidence of trauma above the clavicles to be the strongest predictors associated with the presence of post-traumatic ICH in patients on DOACs. The absence of a concussion seems to indicate subgroups at very low risk of requiring neurosurgery. CONCLUSIONS The machine-based CHAID model identified distinct prognostic groups of patients with distinct outcomes based on clinical factors. Decision trees can be useful as guides for patient selection and risk stratification.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy; Franz Tappeiner Hospital, Azienda Sanitaria dell'Alto Adige, Department of Emergency Medicine Franz Tappeiner Hospital, Azienda Sanitaria dell'Alto Adige, Italy.
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Antonio Maccagnani
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Andrea Tenci
- Department of Emergency Medicine, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | | | - Massimo Zannoni
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Giorgio Ricci
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Antonio Bonora
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria integrata, Verona, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
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Hartmann DA. Managing the tempo of the emergency department as an off-service intern. AEM EDUCATION AND TRAINING 2021; 5:e10577. [PMID: 34124523 PMCID: PMC8171787 DOI: 10.1002/aet2.10577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Affiliation(s)
- David A Hartmann
- Department of Neurology & Neurological SciencesStanford UniversityStanfordCAUSA
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Zhang W, Ma A, Takshe A, Muwafak BM. Establishment of differential model of recovery treatment for children with minor brain injury and mental disorder syndrome. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2021; 18:5614-5624. [PMID: 34517503 DOI: 10.3934/mbe.2021283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The paper established a differential equation model for 194 children with ADHD in outpatient clinics from September 2019 to August 2020 and compiled a children's clinical diagnostic interview scale based on the fourth edition of the American Diagnostic and Statistical Manual of Mental Disorders (DSM-Ⅳ). The CDIS standard divides it into three phenotypes: attention deficit predominant (ADHD-I), hyperactivity-impulsive predominance (ADHD-HI) and mixed (ADHD-C). The results of the study showed that the distribution of subtypes in the study cases: ADHD-I accounted for 45.9% (89 cases), ADHD-HI accounted for 7.7% (15 cases), ADHD-C accounted for 46.4% (90 cases); ADHD-C: ADHD-I is 1:1. CDIS scale total score: 194 cases of attention deficit symptoms were (7.2 ± 1.4) points, and hyperactivity-impulsive symptoms were (5.4 ± 2.2) points. The frequency of attention deficit symptoms in 194 cases was (79.5 ± 2.9) %, and the frequency of hyperactivity-impulsive symptoms was (59.8 ± 3.5) %. Therefore, it can be concluded that DSM-IV defines three phenotypes in this sample. The proportion of ADHD-HI is low, and the proportion of ADHD-I and ADHD-C is similar; age influences the phenotype distribution.
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Affiliation(s)
- Wei Zhang
- China University of Political Science and Law, Beijing 102249, China
| | - Ai Ma
- China University of Political Science and Law, Beijing 102249, China
| | - Aseel Takshe
- Faculty of Environmental Health Sciences, Canadian University Dubai, Dubai, United Arab Emirates
| | - Bishr Muhamed Muwafak
- Department of Accounting and Finace, Faculty of Administrative Sciences, Applied Science University, Al Eker, Kingdom of Bahrain
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Cipriano A, Park N, Pecori A, Bionda A, Bardini M, Frassi F, Lami V, Leoli F, Manca ML, Del Prato S, Santini M, Ghiadoni L. Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs. Intern Emerg Med 2021; 16:1061-1070. [PMID: 33386604 DOI: 10.1007/s11739-020-02576-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 11/17/2020] [Indexed: 01/23/2023]
Abstract
Although mild traumatic brain injury (MTBI) in people on oral anticoagulant treatment (OAT) is a frequent challenge for Emergency Department (ED), strong guidelines recommendations are lacking. In the attempt to assess the safety profile of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs), we have recruited 473 patients with a MTBI on OAT (43.6% males; age 81.8 ± 8.7 years), admitted to the Pisa's University Hospital ED (Jan 2016-Oct 2018). All patients underwent a head CT scan with those with no sign of acute bleedings remaining under clinical observation for the ensuing 24 h. Fifty patients (10.6%, 95% CI: 8.1-13.7%) had immediate intracranial hemorrhage (ICH), with a prevalence of patient-important outcomes due to immediate ICH of 1.1% (95% CI 0.4-2.4%); 3 patients died (0.6%, 95% CI 0.2-1.8) and 2 required neurosurgical intervention. Immediate ICHs were more frequent in VKA-treated than in DOAC-treated patients (15.9 vs. 6.4%. RR 2.5. 95%CI 1.4-4.4. p < 0.05). Multivariate analysis identified that post-traumatic amnesia, evidence of trauma above clavicles, high blood glucose, high blood pressure (BP) at arrival, and low prothrombin activity were predictors of immediate ICH. The prevalence of delayed ICH was 1.0% (95%CI 0.4-2.5%) without differences between DOACs and VKAs. Despite ICH being a frequent complication of MTBI in patients on OAT, immediate and delayed patient-important outcomes are rare. DOACs have a better safety profile than VKAs. Simple clinical parameters such as blood pressure at arrival or blood glucose might provide useful predictors of immediate ICH.Trial registration number: 11924_CIPRIANO. Local ethics committee approval number 33096.
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Affiliation(s)
- Alessandro Cipriano
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy.
| | - Naria Park
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Alessio Pecori
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Alessandra Bionda
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Michele Bardini
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Francesca Frassi
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Valentina Lami
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Francesco Leoli
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Maria Laura Manca
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Massimo Santini
- U.O. Medicina D'Urgenza E Pronto Soccorso, Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, Pisa, Italy
| | - Lorenzo Ghiadoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Turcato G, Zaboli A, Zannoni M, Ricci G, Zorzi E, Ciccariello L, Tenci A, Pfeifer N, Maccagnani A, Bonora A. Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants. Am J Emerg Med 2021; 43:180-185. [DOI: 10.1016/j.ajem.2020.02.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 02/16/2020] [Accepted: 02/22/2020] [Indexed: 12/26/2022] Open
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Hickey S, Hickman ZL, Conway J, Giwa A. The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review. J Emerg Med 2021; 60:321-330. [PMID: 33390300 DOI: 10.1016/j.jemermed.2020.10.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. OBJECTIVE Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. METHODS We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. RESULTS There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. CONCLUSIONS This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.
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Affiliation(s)
- Sean Hickey
- Department of Emergency Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - Zachary L Hickman
- Department of Neurosurgery, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Department of Neurosurgery, NYC Health + Hospitals/Elmhurst, Queens, New York
| | - John Conway
- Department of Emergency Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York
| | - Al Giwa
- Department of Emergency Medicine, Icahn School of Medicine at the Mount Sinai Hospital, New York, New York; Neurotrauma Consortium, Inc., Elmhurst, New York
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Santing JAL, Van den Brand CL, Jellema K. Traumatic Brain Injury in Patients Receiving Direct Oral Anticoagulants. J Emerg Med 2020; 60:285-291. [PMID: 33067068 DOI: 10.1016/j.jemermed.2020.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/19/2020] [Accepted: 09/03/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emergency departments (EDs) are faced with a growing number of patients with traumatic brain injury (TBI) using direct oral anticoagulants (DOACs). However, there remains uncertainty about the bleeding risk, rate of hematoma expansion, and the efficacy of reversal strategies in these patients. OBJECTIVE This study aims to identify the risk of traumatic hemorrhagic complications in patients with TBI using DOACs. METHODS In this retrospective study we included patients with TBI. All TBI patients were using DOACs, attended one of the three EDs of our hospital between January 2016 and October 2019, and received a computed tomography (CT) scan of the brain. The primary outcome was any traumatic intracranial hemorrhage on CT. Secondary outcomes were the use of reversal agents, secondary neurological deterioration, a neurosurgical intervention within 30 days after the injury, length of stay (LOS), Glasgow Outcome Scale (GOS) at discharge, and mortality. RESULTS Of the included patients (N = 316), 24 patients (7.6%, 95% confidence interval [CI] 4.2-9.8) presented with a traumatic intracranial hematoma (ICH). Seven patients (2.2%, 95% CI 0.6-3.8) received a reversal agent and 1 patient (0.3%, 95% CI -0.3-0.9) underwent a neurosurgical intervention. Of the 24 patients with a traumatic ICH, progression of the lesion was seen in 6 patients (1.9%, 95% CI 0.4-3.4). The mean LOS was 6.5 days (95% CI 3.0-10.1) and the mean GOS at discharge was 4 (95% CI 3.6-4.6). Death occurred in 1 patient (0.3%, 95% CI -0.3-0.9) suffering from an ICH. CONCLUSION Based on the present findings it can be postulated that TBI patients using DOACs have a low risk for ICH. Hematoma progression occurred, however, in a substantial number of patients. Considering the retrospective nature of the present study, future prospective trials are needed to confirm this finding.
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Affiliation(s)
| | - Crispijn L Van den Brand
- Department of Emergency Medicine, Haaglanden Medical Center, The Hague, the Netherlands; Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, the Netherlands
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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; 37:666-673. [PMID: 32900858 DOI: 10.1136/emermed-2019-209307] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/23/2020] [Accepted: 08/13/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group. METHODS An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies. RESULTS 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%). CONCLUSIONS The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.
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Affiliation(s)
- Gordon Fuller
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Lisa Sabir
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Rachel Evans
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Daniel Bradbury
- Emergency Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
| | - Maxine Kuczawski
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
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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; 57:817-824. [PMID: 31648805 DOI: 10.1016/j.jemermed.2019.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The risk of intracranial hemorrhage (ICH) in patients taking direct oral anticoagulants (DOACs) after mild traumatic brain injury (MTBI) is unclear. OBJECTIVES To assess the differences in the risk of developing early, delayed, and comprehensive bleeding after MTBI among patients treated with DOACs as compared with those treated with vitamin K antagonists (VKAs). METHODS All MTBI patients taking oral anticoagulants in our emergency department between June 2017 and August 2018 were included. All patients on oral anticoagulants underwent immediate cerebral computed tomography (CT) and a second CT scan after 24 h of clinical observation. RESULTS There were 451 patients enrolled: 268 were on VKAs and 183 on DOACs. Of the DOAC-treated patients, 7.7% (14/183) presented overall intracranial bleeding, compared with 14.9% (40/268) of VKA-treated patients (p = 0.026). Early bleeding was present in 5.5% (10/183) of DOAC-treated patients and in 11.6% (31/268) of VKA-treated patients (p = 0.030). Multivariable analysis showed that VKA therapy (odds ratio [OR] 2.327), high-energy impact (OR 11.229), amnesia (OR 2.814), loss of consciousness (OR 5.286), Glasgow Coma Scale score < 15 (OR 4.719), and the presence of lesion above the clavicles (OR 2.742) were associated with significantly higher risk of global ICH. A nomogram was constructed to predict ICH using these six variables. Discrimination of the nomogram revealed good predictive abilities (area under the receiver operating characteristic curve: 0.817). CONCLUSIONS DOAC-treated patients seem to have lower risk of posttraumatic intracranial bleeding compared with VKA-treated patients.
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