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Clinical Reviews in Emergency Medicine| Volume 51, ISSUE 5, P519-528, November 2016

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

      Abstract

      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.

      Keywords

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      References

        • Maas A.I.
        • Stocchetti N.
        • Bullock R.
        Moderate and severe traumatic brain injury in adults.
        Lancet Neurol. 2008; 7: 728-741
        • Cassidy J.D.
        • Carroll L.J.
        • Peloso P.M.
        • et al.
        Incidence, risk factors and prevention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.
        J Rehabil Med. 2004; : 28-60
        • Kim J.J.
        • Gean A.D.
        Imaging for the diagnosis and management of traumatic brain injury.
        Neurotherapeutics. 2011; 8: 39-53
        • Thomas B.W.
        • Mejia V.A.
        • Maxwell R.A.
        • et al.
        Scheduled repeat CT scanning for traumatic brain injury remains important in assessing head injury progression.
        J Am Coll Surg. 2010; 210 (831–2): 824-830
        • Muakkassa F.F.
        • Marley R.A.
        • Paranjape C.
        • Horattas E.
        • Salvator A.
        • Muakkassa K.
        Predictors of new findings on repeat head CT scan in blunt trauma patients with an initially negative head CT scan.
        J Am Coll Surg. 2012; 214: 965-972
        • Vos P.E.
        • Alekseenko Y.
        • Battistin L.
        • et al.
        Mild traumatic brain injury.
        Eur J Neurol. 2012; 19: 191-198
        • Batchelor J.S.
        • Grayson A.
        A meta-analysis to determine the effect of anticoagulation on mortality in patients with blunt head trauma.
        Br J Neurosurg. 2012; 26: 525-530
        • Mina A.A.
        • Knipfer J.F.
        • Park D.Y.
        • Bair H.A.
        • Howells G.A.
        • Bendick P.J.
        Intracranial complications of preinjury anticoagulation in trauma patients with head injury.
        J Trauma. 2002; 53: 668-672
        • Cohen D.B.
        • Rinker C.
        • Wilberger J.E.
        Traumatic brain injury in anticoagulated patients.
        J Trauma. 2006; 60: 553-557
        • Li J.
        • Brown J.
        • Levine M.
        Mild head injury, anticoagulants, and risk of intracranial injury.
        Lancet. 2001; 357: 771-772
        • Siracuse J.J.
        • Robich M.P.
        • Gautam S.
        • Kasper E.M.
        • Moorman D.W.
        • Hauser C.J.
        Antiplatelet agents, warfarin, and epidemic intracranial hemorrhage.
        Surgery. 2010; 148 (discussion 9–30): 724-729
        • Dossett L.A.
        • Riesel J.N.
        • Griffin M.R.
        • Cotton B.A.
        Prevalence and implications of preinjury warfarin use: an analysis of the National Trauma Databank.
        Arch Surg. 2011; 146: 565-570
        • Pieracci F.M.
        • Eachempati S.R.
        • Shou J.
        • Hydo L.J.
        • Barie P.S.
        Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database.
        J Trauma. 2007; 63: 519-524
        • Grandhi R.
        • Harrison G.
        • Voronovich Z.
        • et al.
        Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.
        J Trauma Acute Care Surg. 2015; 78: 614-621
        • Unden J.
        • Ingebrigtsen T.
        • Romner B.
        Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update.
        BMC Med. 2013; 11: 50
        • Vos P.E.
        • Battistin L.
        • Birbamer G.
        • et al.
        EFNS guideline on mild traumatic brain injury: report of an EFNS task force.
        Eur J Neurol. 2002; 9: 207-219
        • Jagoda A.S.
        • Bazarian J.J.
        • Bruns Jr., J.J.
        • et al.
        Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting.
        Ann Emerg Med. 2008; 52: 714-748
        • Servadei F.
        • Teasdale G.
        • Merry G.
        Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management.
        J Neurotrauma. 2001; 18: 657-664
        • National Institute for Health and Care Excellence
        Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Children, Young People and Adults.
        NICE, London, UK2014
        • Motor Accidents Authority NSW 2008
        Guidelines for Mild Traumatic Brain Injury Following Closed Head Injury.
        Motor Accidents Authority NSW, New South Wales, Australia2013
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • et al.
        Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.
        JAMA. 2000; 283: 2008-2012
        • Moher D.
        • Shamseer L.
        • Clarke M.
        • et al.
        Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement.
        Syst Rev. 2015; 4: 1
        • Carroll L.J.
        • Cassidy J.D.
        • Holm L.
        • Kraus J.
        • Coronado V.G.
        Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.
        J Rehabil Med. 2004; : 113-125
        • Reljic T.
        • Mahony H.
        • Djulbegovic B.
        • et al.
        Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis.
        J Neurotrauma. 2014; 31: 78-98
      1. GA Wells, D O'Connell, J Peterson, V Welch, M Losos, P Tugwell. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed May 25, 2015.

        • Stuart A.
        • Ord K.
        Kendall's Advanced Theory of Statistics.
        John Wiley and Sons, Inc., New York1994
        • Menditto V.G.
        • Lucci M.
        • Polonara S.
        • Pomponio G.
        • Gabrielli A.
        Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol.
        Ann Emerg Med. 2012; 59: 451-455
        • Peck K.A.
        • Sise C.B.
        • Shackford S.R.
        • et al.
        Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk?.
        J Trauma. 2011; 71: 1600-1604
        • Nishijima D.K.
        • Offerman S.R.
        • Ballard D.W.
        • et al.
        Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
        Ann Emerg Med. 2012; 59: 460-468.e1–e7
        • Schoonman G.G.
        • Bakker D.P.
        • Jellema K.
        Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization.
        Eur J Neurol. 2014; 21: 1021-1025
        • Kaen A.
        • Jimenez-Roldan L.
        • Arrese I.
        • et al.
        The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.
        J Trauma. 2010; 68: 895-898
        • McCammack K.C.
        • Sadler C.
        • Guo Y.
        • Ramaswamy R.S.
        • Farid N.
        Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury.
        West J Emerg Med. 2015; 16: 43-49
        • Taylor K.
        • Lymburner P.
        • Challen J.
        Medical imaging in emergency medicine: assessing the use of serial imaging to screen for delayed intracranial haemorrhage in patients on anticoagulant and antiplatelet therapy.
        J Med Imaging Radiat Oncol. 2012; 56: 146-147
        • Eroglu S.E.
        • Onur O.
        • Ozkaya S.
        • Denizbasi A.
        • Demir H.
        • Ozpolat C.
        Analysis of repeated CT scan need in blunt head trauma.
        Emerg Med Int. 2013; 2013: 916253
        • Docimo Jr., S.
        • Demin A.
        • Vinces F.
        Patients with blunt head trauma on anticoagulation and antiplatelet medications: can they be safely discharged after a normal initial cranial computed tomography scan?.
        Am Surg. 2014; 80: 610-613
        • Miller J.
        • Lieberman L.
        • Nahab B.
        • et al.
        Delayed intracranial hemorrhage in the anticoagulated patient: a systematic review.
        J Trauma Acute Care Surg. 2015; 79: 310-313
        • Swap C.
        • Silver M.
        • Krauss W.
        • Sidell M.
        • Ogaz R.
        Risk of intracerebral hemorrhage on repeat head computed tomography scan in anticoagulated patients.
        Ann Emerg Med. 2012; 60: S151
        • Hill J.
        Delayed ICH in the anticoagulated blunt trauma patient: routine repeat head CT is unnecessary.
        Crit Care Med. 2013; 41: S12
        • Cohn B.
        • Keim S.M.
        • Sanders A.B.
        Can anticoagulated patients be discharged home safely from the emergency department after minor head injury?.
        J Emerg Med. 2014; 46: 410-417
        • Pieracci F.M.
        • Eachempati S.R.
        • Shou J.
        • Hydo L.J.
        • Barie P.S.
        Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients.
        J Trauma. 2007; 63: 525-530