Preinjury Antiplatelet Use Does Not Increase the Risk of Progression of Small Intracranial Hemorrhage

Background The modified brain injury guidelines (mBIG) provide an algorithm for surgeons to manage some mild traumatic brain injury (TBI) with intracranial hemorrhage (ICH) without neurosurgical consultation or repeat imaging. Currently, antiplatelet use among patients with any ICH classifies a patient at the highest level, mBIG 3. This study assesses the risk of clinical progression among patients taking antiplatelet medications with mild TBI with ICH. Methods A retrospective analysis of patients with traumatic ICH over a 5-year period was conducted. Demographics, injury severity, and outcome data were collected for each patient. Patients taking antiplatelet agents were reclassified as if they were not taking these medications. Patients who would have met criteria for a lower classification (mBIG 1 or 2) without antiplatelet agents were designated mBIG 3 Antiplatelet and compared with all other mBIG 1 and 2 patients. Results 736 patients met the inclusion criteria. 158 patients were taking antiplatelet medications and 53 were reclassified as mBIG 3 Antiplatelet. When comparing mBIG 3 Antiplatelet to the 226 patients originally classified as mBIG 1 and 2, mBIG 3 Antiplatelet patients were more likely to undergo repeat head computed tomography (98.1% vs 76.6%; P < .001) and neurosurgical consultation (94.2% vs 76.5%; P < .001) but had no significant differences in outcomes. No mBIG 3 Antiplatelet patients had a worsening examination or needed operative intervention. Discussion This data suggests that antiplatelet medication use should not automatically classify a patient as mBIG 3. Adoption of this strategy would better utilize resources and avoid unnecessary costs without sacrificing care.

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Repeat Head Computed Tomography in Anticoagulated Traumatic Brain Injury Patients: Still Warranted

The American Surgeon ◽

10.1177/000313481408000123 ◽

2014 ◽

Vol 80 (1) ◽

pp. 43-47 ◽

Cited By ~ 21

Author(s):

Bellal Joseph ◽

Moutamn Sadoun ◽

Hassan Aziz ◽

Andrew Tang ◽

Julie L. Wynne ◽

...

Keyword(s):

Computed Tomography ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scan ◽

Intracranial Hemorrhage ◽

Injury Severity ◽

Head Ct ◽

Lengths Of Stay ◽

Anticoagulation Agents ◽

Head Computed Tomography

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neuro-surgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ2 and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older ( P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission ( P < 0.001), were more likely to present with an abnormal neurologic examination ( P = 0.004), and had higher hospital and intensive care unit lengths of stay ( P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.

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Does the Presence of Subdural Hemorrhage Increase the Risk of Intracranial Hemorrhage Expansion after the Initiation of Antithrombotic Medication?

The American Surgeon ◽

10.1177/000313481808400327 ◽

2018 ◽

Vol 84 (3) ◽

pp. 416-421 ◽

Cited By ~ 2

Author(s):

Urmil Pandya ◽

Jill Pattison ◽

Chris Karas ◽

Michael O'Mara

Keyword(s):

Intracranial Hemorrhage ◽

Injury Severity ◽

Demographic Data ◽

Clinical Indication ◽

Subdural Hemorrhage ◽

Trauma Patients ◽

Inclusion Criteria ◽

Antiplatelet Medication ◽

Level I ◽

Antithrombotic Medication

Patients with traumatic intracranial hemorrhage (ICH) with a clinical indication for antithrombotic medication present a clinical dilemma, burdened by the task of weighing the risks of hemorrhage expansion against the risk of thrombosis. We sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antithrombotic medication. Medical records of 1626 trauma patients admitted with traumatic ICH between March 1, 2008, and March 31, 2013, to a Level I trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant or antiplatelet medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared with patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma, postinjury day of initiation, and mortality were analyzed. A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other ICH group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the groups. Patients with subdural hemorrhage had a significantly higher rate of ICH expansion (9.1 vs 0%, P = 0.045). There was no difference in overall hospital mortality between the two groups. Incidence of ICH expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury.

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The Utility of Thromboelastography for Predicting The Risk of Progression of Intracranial Hemorrhage in Traumatic Brain Injury Patients

Neurosurgery ◽

10.1093/neuros/nyx210 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 182-187 ◽

Cited By ~ 3

Author(s):

Abigail Rao ◽

Amber Lin ◽

Cole Hilliard ◽

Rongwei Fu ◽

Tori Lennox ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Hemorrhage ◽

Risk Of Progression

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Cerebral sinus venous thrombosis in traumatic brain injury

Emergency Care Journal ◽

10.4081/ecj.2016.5441 ◽

2016 ◽

Vol 1 (1) ◽

Author(s):

Christina Mueller-Hoecker ◽

Urs Pietsch

Keyword(s):

Computed Tomography ◽

Traumatic Brain Injury ◽

Emergency Department ◽

Brain Injury ◽

Injury Severity ◽

Cerebral Sinus Venous Thrombosis ◽

Epidural Hemorrhage ◽

Cerebral Sinus ◽

Head Computed Tomography ◽

Sinus Venous Thrombosis

A 36-year-old, healthy man was admitted to the emergency department with a traumatic brain injury with an injury severity score of 25 points. The head computed tomography revealed a subarachnoidal, epidural hemorrhage as well as a fracture of the occipital calotte. Intracranial pressure (ICP) management was installed according to the LUND concept. In the following scan an angiography revealed a thrombosis of the sinus sigmoideus and transversus. Located next to the fractured skull, the thrombosis was highly likely traumatic, caused by the head trauma. As there was only a little congestion of the blood flow, no lysis or thrombectomy was performed. To lower ICP, a craniectomy was performed. After seven days, mechanical ventilation was terminated. Four days later the patient was already stable enough to be discharged from the surgical itensive care unit.

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185 The Utility of Thromboelastography for Predicting the Risk of Progression of Intracranial Hemorrhage in Traumatic Brain Injury Patients

Neurosurgery ◽

10.1227/01.neu.0000489754.05157.93 ◽

2016 ◽

Vol 63 ◽

pp. 173-174 ◽

Cited By ~ 4

Author(s):

Abigail J. Rao ◽

Amber Laurie ◽

Cole Hilliard ◽

Rochelle Fu ◽

Tori Lennox ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Hemorrhage ◽

Risk Of Progression

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Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury

The American Surgeon ◽

10.1177/0003134820956360 ◽

2020 ◽

pp. 000313482095636

Author(s):

Brandon M. Parker ◽

Jay Menaker ◽

Cherisse D. Berry ◽

Ronald B. Tesoreiero ◽

James V. O’Connor ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Extracorporeal Membrane Oxygenation ◽

Intracranial Hemorrhage ◽

Injury Severity ◽

Traumatic Injury ◽

Bleeding Complications ◽

Absolute Contraindication ◽

Membrane Oxygenation ◽

Vv Ecmo

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) use in patients following traumatic injury continues to increase. Some consider traumatic brain injury (TBI) as an absolute contraindication for VV-ECMO because of the concern for systemic anticoagulation (A/C) worsening intracranial injury. We evaluated outcomes and complications in patients with TBI treated with VV-ECMO. Methods We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate. Results 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C. Conclusion VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.

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Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury

Journal of Neurosurgery ◽

10.3171/2016.5.jns16255 ◽

2018 ◽

Vol 128 (1) ◽

pp. 236-249 ◽

Cited By ~ 8

Author(s):

Jonathan J. Lee ◽

David J. Segar ◽

John F. Morrison ◽

William M. Mangham ◽

Shane Lee ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Hemorrhage ◽

Subdural Hematoma ◽

Injury Severity ◽

Prognostic Models ◽

Short Term ◽

Radiographic Findings ◽

Poor Outcome ◽

Gcs Score

OBJECTIVEEarly radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models.METHODSThe authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present.RESULTSIn general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3–8).CONCLUSIONSIn these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.

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Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?

Journal of Neurosurgery ◽

10.3171/2011.11.jns111092 ◽

2012 ◽

Vol 116 (3) ◽

pp. 549-557 ◽

Cited By ~ 80

Author(s):

Chad W. Washington ◽

Robert L. Grubb

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Ct Scans ◽

Imaging Data ◽

Inclusion Criteria ◽

Mild Tbi ◽

Head Ct ◽

Gcs Score ◽

Repeat Imaging ◽

Neurosurgical Intervention

Object More than 1.5 million Americans suffer a traumatic brain injury (TBI) each year. Seventy-five percent of these patients have a mild TBI, with Glasgow Coma Scale (GCS) Score 13–15. At the authors' institution, the usual practice has been to admit those patients with an associated intracranial hemorrhage (ICH) to an ICU and to obtain repeat head CT scans 12–24 hours after admission. The purpose of this study was to determine if there exists a subpopulation of mild TBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. This group of patients was further classified based on initial clinical factors and imaging characteristics. Methods A retrospective review of all patients admitted to a Level I trauma center from January 2007 through December 2008 was performed using the hospital Trauma Registry Database, medical records, and imaging data. The inclusion criteria were as follows: 1) an admission GCS score ≥ 13; 2) an isolated head injury with no other injury requiring ICU admission; 3) an initial head CT scan positive for ICH; and 4) an initial management plan that was nonoperative. Collected data included age, etiology, initial GCS score, time of injury, duration of ICU stay, duration of hospital stay, and anticoagulation status. Primary outcomes measured were the occurrence of neurological or medical decline and the need for neurosurgical intervention. Imaging data were analyzed and classified based on the predominant blood distribution found on admission imaging. Data were further categorized based on the Marshall CT classification, Rotterdam score, and volume of intraparenchymal hemorrhage (IPH). Progression was defined as an increase in the Marshall classification, an increase in the Rotterdam score, or a 30% increase in IPH volume. Results Three hundred twenty-one of 1101 reviewed cases met inclusion criteria for the study. Only 4 patients (1%) suffered a neurological decline and 4 (1%) required nonemergent neurosurgical intervention. There was a medical decline in 18 of the patients (6%) as a result of a combination of events such as respiratory distress, myocardial infarction, and sepsis. Both patient age and the transfusion of blood products were significant predictors of medical decline. Overall patient mortality was 1%. Based on imaging data, the rate of injury progression was 6%. The only type of ICH found to have a significant rate of progression (53%) was a subfrontal/temporal intraparenchymal contusion. Other variables found to be significant predictors of progression on head CT scans were the use of anticoagulation, an age over 65 years, and a volume of ICH > 10 ml. Conclusions Most patients with mild TBI have a good outcome without the necessity of neurosurgical intervention. Mild TBI patients with a convexity SAH, small convexity contusion, small IPH (≤ 10 ml), and/or small subdural hematoma do not require admission to an ICU or repeat imaging in the absence of a neurological decline.

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Antiplatelet therapy is associated with a high rate of intracranial hemorrhage in patients with head injuries

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000520 ◽

2020 ◽

Vol 5 (1) ◽

pp. e000520

Author(s):

Scott M Alter ◽

Benjamin A Mazer ◽

Joshua J Solano ◽

Richard D Shih ◽

Mary J Hughes ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Head Trauma ◽

Intracranial Hemorrhage ◽

Injury Severity ◽

Head Injuries ◽

Antiplatelet Agents ◽

High Rate ◽

Head Ct ◽

Severity Scores ◽

Blunt Head Trauma

BackgroundAntiplatelet agents are increasingly used in cardiovascular treatment. Limited research has been performed into risks of acute and delayed traumatic intracranial hemorrhage (ICH) in these patients who sustain head injuries. Our goal was to assess the overall odds and identify factors associated with ICH in patients on antiplatelet therapy.MethodsA retrospective observational study was conducted at two level I trauma centers. Adult patients with head injuries on antiplatelet agents were enrolled from the hospitals’ trauma registries. Acute ICH was diagnosed by head CT. Observation and repeat CT to evaluate for delayed ICH was performed at clinicians’ discretion. Patients were stratified by antiplatelet type and analyzed by ICH outcome.ResultsOf 327 patients on antiplatelets who presented with blunt head trauma, 133 (40.7%) had acute ICH. Three (0.9%) had delayed ICH on repeat CT, were asymptomatic and did not require neurosurgical intervention. One with delayed ICH was on clopidogrel and two were on both clopidogrel and aspirin. Patients with delayed ICH compared with no ICH were older (94 vs 74 years) with higher injury severity scores (15.7 vs 4.4) and trended towards lower platelet counts (141 vs 216). Patients on aspirin had a higher acute ICH rate compared with patients on P2Y12 inhibitors (48% vs 30%, 18% difference, 95% CI 4 to 33; OR 2.18, 95% CI 1.15 to 4.13). No other group comparison had significant differences in ICH rate.ConclusionsPatients on antiplatelet agents with head trauma have a high rate of ICH. Routine head CT is recommended. Patients infrequently developed delayed ICH. Routine repeat CT imaging does not appear to be necessary for all patients.Level of evidenceLevel III, prognostic.

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