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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

      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.

      Keywords

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      Linked Article

      • Wrong Cohort to Reduce “Unnecessary” CT Imaging
        Journal of Emergency Medicine
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          We commend the authors on studying a robust database of over 1000 patients taking direct oral anticoagulants (DOACs) who sustained minor head trauma in their article in the current journal entitled “Analysis of clinical and laboratory risk factors of post-traumatic intracranial hemorrhage in patients on DOACs with mild traumatic brain injury: an observational multicenter cohort”. The methodology was sound. We agree with excluding patients who arrived 48 hours after their trauma (asymptomatic after 48 hours would not require head imaging), those that took their last dose of DOAC 24 hours prior to the head trauma (need for imaging does not need to factor in the risk of anticoagulation), and those that arrive with focal deficits (immediate imaging required).
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