Mild Traumatic Brain Injury in Patients on Long-Term Anticoagulation Therapy: Do They Really Need Repeated Head CT Scan?

Introduction: Injured seniors visits are on the rise in the emergency department (ED) and up to 30 % are traumatic brain injury (TBI). Many patients suffer from comorbidities that require the use of anticoagulant drugs. The use of these drugs usually modify the trajectory patients will undergo in the ED. In the last decade, some authors suggested a systematic follow-up CT head scan 8 hours after the initial, while others didn’t see the need to scan, referring only to the clinical features. We sought to evaluate the presence of delayed intracranial bleeding, evolution and investigation at the ED of elderly patients presenting for a mild TBI, with or without anticoagulotherapy. Methods: A retrospective cohort was built with hospital administrative clinical data for year 2014 at a Canadian Level 1 trauma center. Patients 65 years and older with traumatic brain injury and residing in the trauma center catching area were included. Data were extracted from medical files using a standardized collection tool in a consecutive pattern. Patients were classified in three groups: use of anticoagulant drug, use of antiplatelet drug and no anticoagulotherapy. Clinico-administrative data, intervention delay, investigations, comorbidities, medication and physiological status were collected. Intra and extra-hospital data were collected for a period of 90 days and the use of imaging and trajectories were analysed. Univariate and multivariate analysis were conducted. Results: 93 of the 189 TBI injury were mild TBI. The 93 patients were divided in patients using anticoagulotherapy (n = 9, 10 %), using antiplatelet drug (n = 58, 62.4 %) and no use of drug (n = 29, 31.2 %). Each group respectively undergo an initial head CT scan in a proportion of 88.9 %, 93 % and 76 %. Follow-up head CT scan were seen in 43 %, 16 % and 10 %. Delayed intra-cranial hemorrhage were identified in respectively 0 %, 2 % and 0 %. Conclusion: With the increase in patients presenting at Canadian ED for head trauma, our study suggests that anticoagulated elderly patients suffering from a mild traumatic brain injury do not systematically require a follow up CT head scan or longer observation time at the ED. A future clinical decision rule to determine the need of follow-up CT could be of benefit to emergency physicians.

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

Scandinavian Journal of Trauma Resuscitation and Emergency Medicine ◽

10.1186/s13049-021-00936-9 ◽

2021 ◽

Vol 29 (1) ◽

Author(s):

Giorgio Colombo ◽

Mattia Bonzi ◽

Elisa Fiorelli ◽

Alessandro Jachetti ◽

Viviana Bozzano ◽

...

Keyword(s):

Systematic Review ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Antiplatelet Therapy ◽

Mild Traumatic Brain Injury ◽

Meta Analysis ◽

Antiplatelet Agent ◽

Secondary Outcome ◽

Head Ct

Abstract 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.

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What are the strongest indicators of intracerebral hemorrhage in mild traumatic brain injury?

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000717 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000717

Author(s):

Panu Teeratakulpisarn ◽

Phati Angkasith ◽

Thanakorn Wannakul ◽

Parichat Tanmit ◽

Supatcha Prasertcharoensuk ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

High Risk ◽

Ct Scan ◽

Mild Traumatic Brain Injury ◽

Skull Fracture ◽

Brain Ct ◽

Baseline Characteristics ◽

Gcs Score ◽

The Brain

BackgroundAlthough there are eight factors known to indicate a high risk of intracranial hemorrhage (ICH) in mild traumatic brain injury (TBI), identification of the strongest of these factors may optimize the utility of brain CT in clinical practice. This study aimed to evaluate the predictors of ICH based on baseline characteristics/mode of injury, indications for brain CT, and a combination of both to determine the strongest indicator.MethodsThis was a descriptive, retrospective, analytical study. The inclusion criteria were diagnosis of mild TBI, high risk of ICH, and having undergone a CT scan of the brain. The outcome of the study was any type of ICH. Stepwise logistic regression analysis was used to find the strongest predictors according to three models: (1) injury pattern and baseline characteristics, (2) indications for CT scan of the brain, and (3) a combination of models 1 and 2.ResultsThere were 100 patients determined to be at risk of ICH based on indications for CT of the brain in patients with acute head injury. Of these, 24 (24.00%) had ICH. Model 1 found that injury due to motor vehicle crash was a significant predictor of ICH, with an adjusted OR (95% CI) of 11.53 (3.05 to 43.58). Models 2 and 3 showed Glasgow Coma Scale (GCS) score of 13 to 14 after 2 hours of observation and open skull or base of skull fracture to be independent predictors, with adjusted OR (95% CI) of 11.77 (1.32 to 104.96) and 5.88 (1.08 to 31.99) according to model 2.DiscussionOpen skull or base of skull fracture and GCS score of 13 to 14 after 2 hours of observation were the two strongest predictors of ICH in mild TBI.Level of evidenceIII.

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GPR110 ligands reduce chronic optic tract gliosis and visual deficit following repetitive mild traumatic brain injury in mice

Journal of Neuroinflammation ◽

10.1186/s12974-021-02195-y ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Huazhen Chen ◽

Karl Kevala ◽

Elma Aflaki ◽

Juan Marugan ◽

Hee-Yong Kim

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Mild Traumatic Brain Injury ◽

Visual Evoked Potential ◽

Evoked Potential ◽

Optic Tract ◽

Primary Microglia ◽

Visual Dysfunction ◽

The Brain

Abstract Background Repetitive mild traumatic brain injury (mTBI) can result in chronic visual dysfunction. G-protein receptor 110 (GPR110, ADGRF1) is the target receptor of N-docosahexaenoylethanolamine (synaptamide) mediating the anti-neuroinflammatory function of synaptamide. In this study, we evaluated the effect of an endogenous and a synthetic ligand of GPR110, synaptamide and (4Z,7Z,10Z,13Z,16Z,19Z)-N-(2-hydroxy-2-methylpropyl) docosa-4,7,10,13,16,19-hexaenamide (dimethylsynaptamide, A8), on the mTBI-induced long-term optic tract histopathology and visual dysfunction using Closed-Head Impact Model of Engineered Rotational Acceleration (CHIMERA), a clinically relevant model of mTBI. Methods The brain injury in wild-type (WT) and GPR110 knockout (KO) mice was induced by CHIMERA applied daily for 3 days, and GPR110 ligands were intraperitoneally injected immediately following each impact. The expression of GPR110 and proinflammatory mediator tumor necrosis factor (TNF) in the brain was measured by using real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) in an acute phase. Chronic inflammatory responses in the optic tract and visual dysfunction were assessed by immunostaining for Iba-1 and GFAP and visual evoked potential (VEP), respectively. The effect of GPR110 ligands in vitro was evaluated by the cyclic adenosine monophosphate (cAMP) production in primary microglia isolated from adult WT or KO mouse brains. Results CHIMERA injury acutely upregulated the GPR110 and TNF gene level in mouse brain. Repetitive CHIMERA (rCHIMERA) increased the GFAP and Iba-1 immunostaining of glia cells and silver staining of degenerating axons in the optic tract with significant reduction of N1 amplitude of visual evoked potential at up to 3.5 months after injury. Both GPR110 ligands dose- and GPR110-dependently increased cAMP in cultured primary microglia with A8, a ligand with improved stability, being more effective than synaptamide. Intraperitoneal injection of A8 at 1 mg/kg or synaptamide at 5 mg/kg significantly reduced the acute expression of TNF mRNA in the brain and ameliorated chronic optic tract microgliosis, astrogliosis, and axonal degeneration as well as visual deficit caused by injury in WT but not in GPR110 KO mice. Conclusion Our data demonstrate that ligand-induced activation of the GPR110/cAMP system upregulated after injury ameliorates the long-term optic tract histopathology and visual impairment caused by rCHIMERA. Based on the anti-inflammatory nature of GPR110 activation, we suggest that GPR110 ligands may have therapeutic potential for chronic visual dysfunction associated with mTBI.

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