warfarin and Craniocerebral-Trauma

Anticoagulated patients represent an important and increasing proportion of the patients with head trauma attending the ED, but there is no international consensus for their appropriate investigation and management. International guidelines vary and are largely based on a small number of studies, which provide poor-quality evidence for the management of patients taking warfarin. This article provides an overview of the clinical research evidence for CT scanning head-injured patients taking warfarin and a discussion of interpretation of risk and acceptable risk. We aim to provide shop floor clinicians with an understanding of the limitations of the evidence in this field and the limitations of applying 'one-size-fits-all' guidelines to individual patients. There is good evidence for a more selective scanning approach to patients with head injuries taking warfarin than is currently recommended by most guidelines. Specifically, patients without any head injury-related symptoms and GCS score 15 have a reduced risk of adverse outcome and may not need to be scanned. We argue that there is evidence to support an individualised approach to decision to CT scan in mild head injuries on warfarin and that clinicians should feel able to discuss risks with patients and sometimes decide not to scan.

Topics: Aged, 80 and over; Anticoagulants; Choice Behavior; Cost-Benefit Analysis; Craniocerebral Trauma; Decision Support Techniques; Diagnostic Imaging; Female; Humans; Male; Middle Aged; Tomography, X-Ray Computed; Warfarin

A significant population of elderly Americans on warfarin is at risk for immediate and delayed intracranial hemorrhage. This qualitative systematic review ascertains the delayed intracranial hemorrhage risk associated with minor head injury and preinjury warfarin use.. A systematic review using MEDLINE, EMBASE, and the Cochrane Library was performed in August 2014. Cohort studies evaluating delayed intracranial hemorrhage in patients with minor head injuries on warfarin were eligible for inclusion. The definition of delayed hemorrhage was any intracranial bleeding detected subsequent to initial negative brain imaging result following the head injury. Three authors screened and abstracted the data and evaluated methodological quality. Data abstraction also included clinical characteristics that could identify risk factors for delayed intracranial hemorrhage.. The search retrieved 294 unique articles, of which 5 studies constituted the final review. The studies included data on 1,257 patients. Among higher-quality studies, the incidence of delayed intracranial hemorrhage ranged from 5.8 to 72 per 1,000 cases of patients on warfarin with minor head injury. Population age was an influential factor in this range of incident rates. International normalized ratio levels had no clear association with individual risk for delayed intracranial hemorrhage.. The incidence of delayed intracranial hemorrhage is low among patients on warfarin with minor head injury. Trauma centers should consider the characteristics of the population they serve compared with the published studies when determining management strategies for these patients.. Systematic review, level III.

Topics: Anticoagulants; Craniocerebral Trauma; Humans; Incidence; Intracranial Hemorrhages; Risk Assessment; Risk Factors; Time Factors; Warfarin

A short-cut review was carried out to determine whether the International Normalised Ratio (INR) value was a predictor of the risk of intracranial haemorrhage in patients taking warfarin after head injury. 796 papers were found using the reported search, of which eighteen were directly relevant. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses are shown in the accompanying table. It is concluded that level of the INR correlates poorly with the risk of haemorrhage and that the risk of haemorrhage remains significant even in patients with a sub-therapeutic INR.

Topics: Aged; Anticoagulants; Craniocerebral Trauma; Evidence-Based Emergency Medicine; Female; Humans; International Normalized Ratio; Intracranial Hemorrhages; Predictive Value of Tests; Risk Factors; Warfarin

A short-cut review was carried out to determine whether patients on warfarin with a minor head injury can be discharged safely if they have a normal CT scan. 796 papers were found using the reported search, of which seven were considered relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses are shown in the accompanying table. It is concluded that the risk of delayed intracranial haemorrhage, at least in patients with an INR <3, is extremely small and discharge of these patients should be considered.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Craniocerebral Trauma; Evidence-Based Emergency Medicine; Female; Humans; Intracranial Hemorrhages; Patient Discharge; Radiography; Warfarin

Patients on warfarin are increasingly common in an ageing population. Previously published case series and cohort studies have resulted in conflicting conclusions with regard to the risk of fatal intracranial haemorrhage. The aim of this study was to undertake a meta-analysis in order to compare the mortality rate of anticoagulated head injured patients against the mortality rate of head injured patients not on coumarin anticoagulation.. The databases Medline and EMBASE were searched via the ovid interface. The initial search strategy returned 364 results. A second search was performed using Pubmed to identify possible abstracts missed by the first search. Forty-seven full articles were reviewed if the abstract suggested that they were either case control studies or nested case control studies comparing the mortality rate of anticoagulated head injured patients against the mortality rate of head injured patients not on coumarin anticoagulation.. Eleven papers were identified, which met the criteria for the meta-analysis. Despite the heterogeneity between the studies (Q test: 27.421, 10 DF, P = 0.002), the fixed effects model may be the preferred model based on the fact that 10 out of the 11 studies had an odds ratio greater than one. The fixed effects model produced a common odds ratio for death in anticoagulated patients with blunt head trauma of 2.008 (95% CI 1.634 - 2.467).. The results of this meta-analysis has shown that the cohort of patients who are anticoagulated and suffer blunt head trauma appear to have an increased risk of death compared to a similar cohort of head injured patients who are not anticoagulated.

Topics: Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Epidemiologic Methods; Humans; Intracranial Hemorrhages; Warfarin; Wounds, Nonpenetrating

Approximately 1% of the UK population receives anticoagulation with warfarin. Head injury accounts for some 1.4 million emergency department attendances in the country. Therefore, significant numbers of patients with head injury have a therapeutic coagulopathy. This review aims to examine the existing evidence for optimal management of warfarinised head injured patients, particularly with respect to the need for early CT imaging and the use of reversal agents in cases of proved haemorrhage.

Topics: Anticoagulants; Craniocerebral Trauma; Emergency Service, Hospital; Hemorrhage; Humans; Warfarin

Topics: Administration, Oral; Anticoagulants; Craniocerebral Trauma; Drug Administration Schedule; Drug Interactions; Drug Monitoring; Hemorrhage; Humans; International Normalized Ratio; Perioperative Care; Platelet Aggregation Inhibitors; Pulmonary Embolism; Venous Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Cerebral Hemorrhage; Craniocerebral Trauma; Evidence-Based Emergency Medicine; Female; Humans; International Normalized Ratio; Patient Discharge; Risk Assessment; Warfarin; Watchful Waiting

Falls are always a concern regarding the balance of risk/benefit in patients with atrial fibrillation treated with anticoagulants. In this analysis, we aimed to evaluate the outcomes of patients that had a fall/head injury reported in the RE-LY clinical trial (Randomized Evaluation of Long-Term Anticoagulation Therapy) and to explore the safety of dabigatran (a nonvitamin K antagonist oral anticoagulant).. We performed a post hoc retrospective analysis of intracranial hemorrhage and major bleeding outcomes in the RE-LY trial with 18 113 individuals with atrial fibrillation, according to the status occurrence of falls (or head injury) reported as adverse events. Multivariate Cox regression models were used to provide adjusted hazard ratio (HR) and 95% CI.. In the study, 974 falls or head injury events were reported among 716 patients (4%). These patients were older and had more frequently comorbidities such as diabetes, previous stroke, or coronary artery disease. Patients with fall had a higher risk of major bleeding (HR, 2.41 [95% CI, 1.90-3.05]), intracranial hemorrhage (HR, 1.69 [95% CI, 1.35-2.13]), and mortality (HR, 3.91 [95% CI, 2.51-6.10]) compared to those who did not have reported falls or head injury. Among patients who had falls, those allocated to dabigatran showed a lower intracranial hemorrhage risk (HR, 0.42 [95% CI, 0.18-0.98]) compared with warfarin.. In this population, the risk of falls is important and confers a worse prognosis, increasing intracranial hemorrhage, and major bleeding. Patients who fell and were under dabigatran was associated with lower intracranial hemorrhage risk than those anticoagulated with warfarin, but the analysis was merely exploratory.

Topics: Accidental Falls; Anticoagulants; Atrial Fibrillation; Craniocerebral Trauma; Dabigatran; Hemorrhage; Humans; Intracranial Hemorrhages; Retrospective Studies; Stroke; Warfarin

Liu S, McLeod SL, Atzema CL, et al.

Topics: Adult; Aged; Anticoagulants; Craniocerebral Trauma; Humans; Intracranial Hemorrhages; Retrospective Studies; Warfarin

To evaluate the efficacy and complications of subgaleal drain placement after two burr-holes evacuation of chronic subdural hematoma (CSDH).. Descriptive study.. The Neurosurgical unit of the Lady Reading Hospital, Peshawar, from April to November 2021.. Sixty-four consecutive patients diagnosed with surgically significant unilateral chronic subdural hematoma were prospectively included after obtaining informed consent. All the patients underwent two burr-holes craniectomies and evacuation, followed by subgaleal drain placement. Patient demographics, pre- and postoperative clinical information including hematoma resolution and complications were collected.. This study included 44 (69%) males and 20 (31%) females with a mean age of 70.1 ± 8 years. The most common presenting symptoms were headaches (70%) and confusion (68%). Eighteen patients (28%) were taking warfarin or other anticoagulants, whereas, 23 patients (36%) were taking antiplatelet medications at the time of presentation. Thirty-six (56.3%) patients had a history of head trauma. Warfarin use was statistically significant in the patients with no history of head injury. Fifty-five patients (85%) showed no significant recurrence on the 2 week postoperative computed tomography (CT) scan. None of the patients had intraparenchymal hematoma or contusion of iatrogenic origin on postoperative CT scans.. Subgaleal drain placement after two burr-holes craniectomy led to high-resolution rates. However, no parenchymal injuries were attributed to the procedure.. Chronic subdural hematoma, Subdural drain, Subperiosteal drain, Burr-hole craniostomy.

Topics: Aged; Craniocerebral Trauma; Craniotomy; Drainage; Female; Hematoma, Subdural, Chronic; Humans; Male; Middle Aged; Recurrence; Retrospective Studies; Treatment Outcome; Trephining; Warfarin

The aim of this paper is to assess the acute haemorrhage rate in patients who had CT head investigation out-of-hours with and without trauma and compare the rates of haemorrhage between warfarin and DOACs, at a busy teritary teaching hospital.. All CT heads performed between January 2008 and December 2019 were identified from the radiology information system (RIS) at Sheffield Teaching Hospitals (STH), with the requesting information being available from January 2015. The clinical information was assessed for the mention of trauma or anticoagulation, and the reports were categorised into acute and non-acute findings.. Between 2008 and 2019 the number of scans increased by 63%, with scans performed out of hours increasing by 278%. Between 2015 and 2019, the incidence of acute ICH was similar over the 5-year period, averaging at 6.9% and ranging from 6.1 to 7.6%. The rate of detection of acute haemorrhage following trauma was greater in those not anticoagulated (6.8%), compared with patients on anticoagulants such as warfarin (5.2%) or DOACs (2.8%).. Over 12 years, there has been a significant increase in the number of CT heads performed at STH. The rate of ICH has remained steady over the last 5 years indicating a justified increase in imaging demand. However, the incidence of ICH in patients prescribed DOACs is lower than the general population and those on warfarin.. This finding in a large centre should prompt discussion of the risk of bleeding with DOACs in relation to CT head imaging guidelines.

Topics: Adolescent; Adult; After-Hours Care; Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Factor Xa Inhibitors; Female; Humans; Intracranial Hemorrhages; Male; Middle Aged; Tomography, X-Ray Computed; Trauma Centers; United Kingdom; Warfarin; Young Adult

In trauma patients using warfarin, current guidelines recommend computed tomography of the brain (CTH), 24-hour observation, and repeat CTH to monitor for stability. Despite growing evidence of uncommon delayed hemorrhage, this remains standard practice even in mild traumatic brain injury without intracranial hemorrhage (ICH). Our study sought to determine the incidence and outcomes of delayed ICH (DICH) in trauma patients on supra-therapeutic warfarin without initial ICH.. A retrospective, single institutional study was performed of all adult trauma patients (>18 years old) who presented on prehospital warfarin with an international normalized ratio (INR) >3 and initial CTH that did not demonstrate ICH. Each of these patients underwent subsequent CTH within 24 hours and any DICH was identified. Those who demonstrated DICH were further examined to identify potential risk factors and outcomes such as need for further imaging or surgical intervention. Analyses were performed using Fisher's exact tests and Student's t-tests.. 225 patients were identified from January 2015 to April 2021 that met inclusion criteria. Of those identified, only 3 (1.33%) were found to develop any DICH on routine repeat CTH. Identified characteristics did not reach statistical significance due to the low number of DICH. None of the patients with DICH went on to require intervention.. In patients with identified traumatic injury on supra-therapeutic warfarin, an initial CTH without identified ICH alone is an adequate survey. DICH in these patients is uncommon and routine reimaging within 24 hours is unlikely to change clinical management in patients with intact neurologic status.

Topics: Adolescent; Adult; Anticoagulants; Craniocerebral Trauma; Humans; Intracranial Hemorrhages; Retrospective Studies; Warfarin

Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated.. Cohort study using administrative data from Ontario of patients ≥ 65 years presenting to the ED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status.. 69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1).. There was an increased odds of delayed intracranial hemorrhage within 90 days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.. RéSUMé: INTRODUCTION: Les patients âgés sous anticoagulation orale sont fréquemment accueillis dans les services d'urgence. L'anticoagulation orale, en particulier la warfarine, est associée à un risque accru d'hémorragie intracrânienne après un traumatisme crânien. Les données sur les saignements retardés chez les patients anticoagulés sont limitées. L'objectif de cette étude était d'examiner le risque d'hémorragie intracrânienne tardive chez les patients se présentant aux urgences avec un traumatisme crânien et anticoagulés avec de la warfarine ou un anticoagulant oral direct, par rapport aux patients non anticoagulés. MéTHODES: Étude de cohorte utilisant les données administratives de l'Ontario des patients ≥ 65 ans se présentant aux urgences avec une plainte de traumatisme crânien entre 2016 et 2018. L'issue primaire était l'hémorragie intracrânienne tardive, définie comme un nouveau code CIM-10 pour une hémorragie intracrânienne dans les 90 jours suivant la visite initiale aux urgences où aucune hémorragie intracrânienne n'a été diagnostiquée. La principale variable d'exposition était le recours à l'anticoagulation orale, qui était une variable à trois niveaux (warfarine, anticoagulants oraux directs ou pas d'anticoagulation orale). Nous avons utilisé une régression logistique multivariable pour déterminer les chances d'hémorragie intracrânienne tardive en fonction du statut d'anticoagulation. RéSULTATS: 69 321 patients ont été inclus : 58 233 (84,0 %) n'avaient pas reçu de prescription d'anticoagulant oral, 3 081 (4,4 %) avaient une prescription de warfarine et 8 007 (11,6 %) avaient une prescription directe d'anticoagulant oral. Dans l'ensemble, 718 (1,0 %) patients ont présenté une hémorragie intracrânienne tardive dans les 90 jours suivant leur visite aux urgences pour un traumatisme crânien. Parmi les patients non anticoagulés, 586 (1,0 %) ont eu une hémorragie intracrânienne retardée, 54 (1,8 %) patients sous warfarine et 78 (1,0 %) patients sous anticoagulant oral direct ont eu une hémorragie intracrânienne retardée. Le risque d'hémorragie intracrânienne tardive était plus élevé avec l'utilisation de la warfarine qu'en l'absence d'anticoagulation (OR : 1,5, IC 95 % : 1,1-2,1). Il n'y avait pas d'association entre l'hémorragie intracrânienne tardive et l'utilisation d'anticoagulants oraux directs par rapport à l'absence d'anticoagulation (OR : 0,9, IC 95 % : 0,6-1,1). CONCLUSIONS: Il y avait une probabilité accrue d'hémorragie intracrânienne re

Topics: Aged; Anticoagulants; Cohort Studies; Craniocerebral Trauma; Emergency Service, Hospital; Hemorrhage; Humans; Intracranial Hemorrhages; Retrospective Studies; Warfarin

Intracranial hemorrhage (ICH) after head injury is a concern among older adult patients on anticoagulation. We evaluated the risk of ICH after an emergency department visit for head injury among patients 65 years and older taking warfarin or a direct oral anticoagulant (DOAC) compared with patients not taking anticoagulants. We also evaluated risk of 30-day mortality and neurosurgical intervention among patients with ICH.. In this retrospective cohort study, we used population-based data of patients 65 years and older seen in an Ontario emergency department with a head injury. We matched patients on the propensity score to create 3 pairwise-matched cohorts based on anticoagulation status (warfarin v. DOAC, warfarin v. no anticoagulant, DOAC v. no anticoagulant). For each cohort, we calculated the relative risk of ICH at the index emergency department visit and 30-day mortality. We also calculated the hazard of neurosurgical intervention among patients with ICH.. We identified 77 834 patients with head injury, including 64 917 (83.4%) who were not on anticoagulation, 9214 (11.8%) who were on DOACs and 3703 (4.8%) who were on warfarin. Of these, 5.9% of patients had ICH at the index emergency department visit. Patients on warfarin had an increased risk of ICH compared with matched patients on DOACs (relative risk [RR] 1.43, 95% confidence interval [CI] 1.20-1.69) and patients not on anticoagulation (RR 1.36, 95% CI 1.15-1.61). We did not observe a difference in ICH between patients on DOACs compared with matched patients not on anticoagulation. In patients with ICH, 30-day mortality did not differ by anticoagulation status or type. Patients on warfarin had an increased hazard of neurosurgery compared with patients not on anticoagulation.. Patients on warfarin seen in the emergency department with a head injury had higher relative risks of ICH than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of ICH for patients on a DOAC was not significantly different compared with no anticoagulation. Further research should confirm that older adults using warfarin are the only group at higher risk of ICH after head injury.

Topics: Accidental Falls; Aged; Anticoagulants; Craniocerebral Trauma; Emergency Service, Hospital; Female; Hospital Mortality; Humans; Intracranial Hemorrhages; Male; Ontario; Retrospective Studies; Warfarin

Head injury is a frequent reason for admission to the emergency department. In parallel, there is a growing use of anticoagulants in an increasingly aging population, which renders this particular group of trauma patients more frequent. In several countries, including Portugal, a 24-h surveillance period followed by repetition of head computed tomography (CT) is the standard procedure for these patients. However, these recommendations have not been based on studies of prevalence of intracranial hemorrhages in control head CTs, namely in this group of anticoagulated patients. This study intends to evaluate the prevalence of de novo intracranial hemorrhages in control head CTs in anticoagulated patients.. An observational study was carried out, which included patients admitted to Hospital de Braga between June 2017 and January 2018, victims of head injury and on anticoagulation therapy, whose admission head CT excluded intracranial hemorrhage.. We collected a total of 201 patients, with a mean age of 81.6 years, and 57.5% of them were prescribed warfarin; 181 of these patients repeated the head CT 24 h later. Of these 181 patients, 3 (1.66%) exhibited intracranial hemorrhage in control CT, without surgical indication. All patients were followed up 1 month after the trauma, and there was no readmission requiring hospitalization, surgery or death.. In conclusion, de novo intracranial hemorrhage in control head CT of anticoagulated patients is rare. We propose that these patients may be discharged if the admission CT does not reveal intracranial hemorrhage, providing that they are accompanied by a caregiver and informed about red flags.

Topics: Aged; Anticoagulants; Craniocerebral Trauma; Humans; Infant, Newborn; Intracranial Hemorrhages; Retrospective Studies; Tomography, X-Ray Computed; Warfarin

Incidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH.. Utilizing INR to risk stratify head trauma patients who may be managed without repeat imaging.. This was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count.. There were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6-3.0), three of which might have been present on initial HCT; incidence rate of 0.51-1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval [CI] 47.8-100), specificity 21% (95% CI 16.6-28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281).. No patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT.

Topics: Aged; Anticoagulants; Craniocerebral Trauma; Female; Glasgow Coma Scale; Humans; Injury Severity Score; International Normalized Ratio; Intracranial Hemorrhages; Male; Predictive Value of Tests; Retrospective Studies; Risk Assessment; Tomography, X-Ray Computed; Trauma Centers; Warfarin

The number of trauma patients on prehospital novel oral anticoagulants (NOACs) is increasing. After an initial negative computed tomography of the head (CTH), practice patterns are variable for obtaining repeat CTH to evaluate for delayed intracranial hemorrhage (ICH-d). However, the risks and outcomes of ICH-d for patients on NOACs are unclear. We hypothesized that, for these patients, the incidence of ICH-d is low, similar to that of warfarin, and when it occurs, it does not result in clinically significant worse outcomes.. Five level 1 trauma centers in Northern California participated in a retrospective review of anticoagulated trauma patients. Patients were included if their initial CTH was negative. Primary outcomes were incidence of ICH-d, neurosurgical intervention, and death. Patient factors associated with the outcome of ICH-d were determined by multivariable regression.. From 2016 to 2018, 777 patients met the inclusion criteria (NOAC, n = 346; warfarin, n = 431), 54% of whom received a repeat CTH. Delayed intracranial hemorrhage incidence was 2.3% in the NOAC group and 4% in the warfarin group (p = 0.31). No NOAC patient with ICH-d required neurosurgical intervention or died because of their head injury. Two warfarin patients received neurosurgical intervention, and three died from their head injury. Head Abbreviated Injury Scale ≥3 was associated with increased odds of developing ICH-d (adjusted odds ratio, 32.70; p < 0.01).. The incidence of ICH-d in patients taking NOAC is low. In this study, patients on NOACs who developed ICH-d after an initial negative CTH did not need neurosurgical intervention or die from their head injury. Repeat CTH in this patient population does not appear necessary.. Prognostic/epidemiologic study, level III.Therapeutic, level IV.

Topics: Administration, Oral; Anticoagulants; California; Craniocerebral Trauma; Humans; Incidence; Intracranial Hemorrhages; Practice Patterns, Physicians'; Prognosis; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed; Unnecessary Procedures; Warfarin

The correlation between direct oral anticoagulants (DOACs) or Vitamin K Antagonist (VKAs) intake and the incidence of intracranial complications after minor head injury (MHI) is still object of debate: preliminary observation seems to demonstrate lower incidence in intracranial bleeding complications (ICH) in patients taking DOACs than VKA. METHODS. This prospective and observational study was performed to clarify the incidence of ICH in patients in DOACs compared to VKAs. Between January 2016 and April 2018 we have recorded in our ED patients with MHI taking oral anticoagulants. Their hemorragic risk score was calculated and recorded for each patient (Has Bled, Atria and Orbit). RESULTS A total of 402 patients with MHI taking anticoagulant were collected: 226 were receiving one of the four DOACs (dabigatran, rivaroxaban, apixaban or edoxaban) while 176 patients were in therapy with VKA. The rate of intracranial complications was significantly lower in patients receiving DOACs than in patients treated with VKA (p < 0.01). In the VKA group two patients died because of intracranial bleeding. No deaths were recorded in the DOACs group. DISCUSSION patients with MHI who take DOACs have a significant lower incidence of intracranial bleeding complications than those treated with vitamin k antagonists. This statement is supported by the observation that the hemorrhagic risk, measured according to the chosen scores, was similar between the two groups.

Topics: Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Dabigatran; Female; Humans; Intracranial Hemorrhages; Male; Middle Aged; Pyrazoles; Pyridines; Pyridones; Risk; Rivaroxaban; Thiazoles; Vitamin K; Warfarin

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Craniocerebral Trauma; Dabigatran; Gastrointestinal Hemorrhage; Humans; Intracranial Hemorrhages; Pyrazoles; Pyridines; Pyridones; Stroke; Thiazoles; Warfarin

We queried our Trauma Quality Improvement Program registry for patients who presented between 6/1/2011 and 9/1/2015 with severe (injury severity score (ISS)>15) blunt traumatic injury during anticoagulant use. Patients were then grouped into those prescribed warfarin and patients prescribed any of the available novel Direct Oral Anticoagulants (DOAC) medications. We excluded severe (AIS≧4) head injuries.. There were no differences between DOAC and warfarin groups in terms of age, gender mean ISS, median hospital or intensive care unit lengths of stay, complication proportions, numbers of complications per patient, or the proportion of patients requiring transfusion. Finally, excluding patients who died, the observed proportion of discharge to skilled nursing facility was similar. In our sample of trauma patients, DOAC use was associated with significantly lower mortality (DOAC group 8.3% vs. warfarin group 29.5%, p<0.015). The ratio of units transfused per patient was also lower in the DOAC group (2.8±1.8 units/patient in the DOAC group vs. 6.7±6.4 units per patient in the warfarin group; p=0.001).. In conclusion, we report an association with decrease in mortality and a decrease in transfused blood products in severely injured trauma patients with likely minimal or no head injury taking novel DOACs over those anticoagulated with warfarin for outpatient anticoagulation.

Topics: Abdominal Injuries; Aged; Anticoagulants; Blood Coagulation Tests; Craniocerebral Trauma; Female; Hemorrhage; Humans; International Normalized Ratio; Male; Quality Improvement; Registries; Retrospective Studies; Trauma Centers; Trauma Severity Indices; United States; Warfarin; Wounds, Nonpenetrating

We investigated delayed outcomes of patients with minor head injury, warfarin, and a normal initial head computer tomographic (CT) scan finding.. We conducted a single-center, retrospective study on such patients who were admitted. A second CT was not mandatory. International normalized ratios were classified into subtherapeutic, therapeutic, and supratherapeutic ranges. We traced them 2 weeks after discharge for delayed intracranial hemorrhage (ICH). Primary outcomes were proportions with ICH on second CT, fresh-frozen plasma (FFP) and/or vitamin K administration, and neurosurgical intervention. Secondary outcomes were hospital length of stay and the proportion with ICH 2 weeks after discharge. We explored differences in proportions of ICH during hospital stay among different strata (age ≥65 years, antiplatelet therapy, supratherapeutic international normalized ratio ranges, and FFP administration). Data were analyzed using descriptive statistics. P values less than .05 were considered statistically significant.. We recruited 298 patients. Of admissions (N = 295), 11 (3.7%) had a second CT, with one (0.3%) abnormality. There were 7 (2.4%) and 8 (2.7%) patients who received FFP and vitamin K, respectively. One patient (0.3%) required neurosurgical intervention. The median hospital length of stay was 3 (interquartile range, 2) days. No patients reattended 2 weeks after discharge. There were no statistically significant differences in the proportions of ICH during hospital stay among the 4 strata.. Delayed ICH was rare with no predictive factors. Clinical monitoring before deciding on second CT was safe. The optimal period and mode of observation had yet to be determined.

Topics: Aged; Anticoagulants; Craniocerebral Trauma; Female; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Retrospective Studies; Risk Factors; Time Factors; Tomography, X-Ray Computed; Warfarin

Bleeding represents the most well-known and the most feared complications caused by the use of antithrombotic agents. There is, however, limited documentation whether pre-injury use of antithrombotic agents affects outcome after head trauma. The aim of this study was to define the relationship between the use of preinjury antithrombotic agents and mortality among elderly people sustaining blunt head trauma.. A retrospective cohort analysis was performed on the hospital based trauma registry at Oslo University Hospital. Patients aged 55 years or older sustaining blunt head trauma between 2004 and 2006 were included. Multivariable logistic regression analyses were used to identify independent predictors of 30-day mortality. Separate analyses were performed for warfarin use and platelet inhibitor use.. Of the 418 patients admitted with a diagnosis of head trauma, 137 (32.8 %) used pre-injury antithrombotic agents (53 warfarin, 80 platelet inhibitors, and 4 both). Seventy patients died (16.7 %); 15 (28.3 %) of the warfarin users, 12 (15.0 %) of the platelet inhibitor users, and two (50 %) with combined use of warfarin and platelet inhibitors, compared to 41 (14.6 %) of the non-users. There was a significant interaction effect between warfarin use and the Triage Revised Trauma Score collected upon the patients' arrival at the hospital. After adjusting for potential confounders, warfarin use was associated with increased 30-day mortality among patients with normal physiology (adjusted OR 8,3; 95 % CI, 2.0 to 34.8) on admission, but not among patients with physiological derangement on admission. Use of platelet inhibitors was not associated with increased mortality.. The use of warfarin before trauma was associated with increased 30-day mortality among a subset of patients. Use of platelet inhibitors before trauma was not associated with increased mortality. These results indicate that patients on preinjury warfarin may need closer monitoring and follow up after trauma despite normal physiology on admission to the emergency department.

Topics: Aged; Aged, 80 and over; Craniocerebral Trauma; Drug Therapy, Combination; Emergency Service, Hospital; Female; Fibrinolytic Agents; Humans; Injury Severity Score; Logistic Models; Male; Middle Aged; Platelet Aggregation Inhibitors; Retrospective Studies; Trauma Centers; Warfarin

It is not currently clear whether all anticoagulated patients with a head injury should receive CT scanning or only those with evidence of traumatic brain injury (eg, loss of consciousness or amnesia). We aimed to determine the cost-effectiveness of CT for all compared with selective CT use for anticoagulated patients with a head injury.. Decision-analysis modelling of data from a multicentre observational study.. 33 emergency departments in England and Scotland.. 3566 adults (aged ≥16 years) who had suffered blunt head injury, were taking warfarin and underwent selective CT scanning.. Estimated expected benefits in terms of quality-adjusted life years (QALYs) were the entire cohort to receive a CT scan; estimated increased costs of CT and also the potential cost implications associated with patient survival and improved health. These values were used to estimate the cost per QALY of implementing a strategy of CT for all patients compared with observed practice based on guidelines recommending selective CT use.. Of the 1420 of 3534 patients (40%) who did not receive a CT scan, 7 (0.5%) suffered a potentially avoidable head injury-related adverse outcome. If CT scanning had been performed in all patients, appropriate treatment could have gained 3.41 additional QALYs but would have incurred £193 149 additional treatment costs and £130 683 additional CT costs. The incremental cost-effectiveness ratio of £94 895/QALY gained for unselective compared with selective CT use is markedly above the threshold of £20-30 000/QALY used by the UK National Institute for Care Excellence to determine cost-effectiveness.. CT scanning for all anticoagulated patients with head injury is not cost-effective compared with selective use of CT scanning based on guidelines recommending scanning only for those with evidence of traumatic brain injury.. NCT 02461498.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cost-Benefit Analysis; Craniocerebral Trauma; Decision Support Techniques; Emergency Service, Hospital; England; Female; Glasgow Outcome Scale; Humans; Male; Middle Aged; Practice Guidelines as Topic; Prospective Studies; Quality-Adjusted Life Years; Scotland; Tomography, X-Ray Computed; Warfarin; Young Adult

There is little evidence to guide physicians on management of patients who sustain head injuries while on warfarin.. Our objective was to determine the rate of intracranial bleeding in anticoagulated patients with minor and minimal head injuries and the association with clinical features and international normalized ratio (INR).. We conducted a historical cohort study of adult patients, taking warfarin, at two tertiary care emergency departments over 2 years with minor (Glasgow Coma Score 13-15, with loss of consciousness, amnesia, or confusion) or minimal (Glasgow Coma Score 15 without loss of consciousness, amnesia, or confusion) head injuries. Patients with penetrating injuries, INR < 1.5, or a new focal neurological deficit were excluded. Our outcome, intracranial bleeding, was determined by the radiologist's final computed tomography (CT) report for imaging performed within 2 weeks.. There were 176 patients enrolled, of which 157 (89.2%) had CT and 28 (15.9%) had intracranial bleeding. Comparing patients with and without intracranial bleeding found no significant differences in INR, and loss of consciousness was associated with higher rate of intracranial bleeding. The rate of intracranial bleeding in the minor and minimal head injury groups was 21.9% and 4.8%, respectively.. The rate of intracranial bleeding in patients on warfarin is considerable. Loss of consciousness is associated with high rates of intracranial bleeding. This study supports a low threshold for ordering CT scans for anticoagulated patients with head injuries.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Craniocerebral Trauma; Emergency Service, Hospital; Female; Humans; Intracranial Hemorrhages; Male; Middle Aged; Risk Factors; Tomography, X-Ray Computed; Warfarin

To define the relationship between preinjury warfarin use and mortality in a large European sample of trauma patients.. A multicentred study was conducted using data collated from European (predominately English and Welsh) trauma receiving hospitals. Patient data from the Trauma Audit and Research Network database from 2009 to 2013 were analysed. Univariate and multivariate logistic regression was used to estimate OR for mortality associated with preinjury warfarin use in the whole adult trauma cohort and a matched sample of patients comparable in terms of age, gender, GCS, pre-existing medical conditions and injury severity.. A total of 136 617 adult trauma patients (2009-2013) were included, with 499 patients reported to be using warfarin therapy at the time of trauma. Preinjury warfarin use was associated with a significantly higher mortality rate at 30 days postinjury compared with the non-users. Following adjustment of age, injury severity and GCS, preinjury warfarin use was associated with increased mortality in trauma patients (adjusted OR 2.14; 95% CI 1.66 to 2.76; p<0.001). In the matched subset, 22% of warfarinised trauma patients died compared with 16.3% of non-warfarinised trauma patients with comparable age, injury severity and GCS (adjusted OR 1.94; 95% CI 1.25 to 3.01; p=0.003).. Preinjury warfarin use has been demonstrated to be an independent predictor of mortality in trauma patients. Clinicians managing major trauma patients on warfarin need to be aware of the vulnerability of this group.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Europe; Female; Glasgow Coma Scale; Hospital Mortality; Humans; Injury Severity Score; Intracranial Hemorrhages; Logistic Models; Male; Middle Aged; Odds Ratio; Retrospective Studies; Sex Factors; Trauma Centers; Warfarin; Wounds and Injuries; Young Adult

Warfarin therapy increases the incidence intracranial hemorrhage (ICH), especially in the geriatric population. Timely reversal of international normalized ratio (INR) is integral in the management of these patients for whom fresh frozen plasma (FFP) with vitamin K is the standard of treatment. We hypothesized that implementing a protocol that used prothrombin complex concentrate (PCC) would reverse INR values more swiftly and decrease the amount of FFP administered. In November 2011, a protocol was implemented for administering PCC to the geriatric population on warfarin admitted for life-threatening bleeds. These patients received 25 IU/kg ideal body weight of a three-factor PCC (Profilnine SD) if their INR was over 1.5 or greater. FFP was given if follow-up INR revealed an INR of 1.5 or greater. Retrospectively the data from 29 patients who received PCC were compared with a historical control group of 34 patients. Protocol use resulted in a significantly faster INR reversal (PCC: 151.6 ± 84.3 minutes vs control: 485.0 ± 321 minutes; P < 0.001), time to achieve an INR less than 1.5 (PCC: 484 ± 242 minutes vs control: 971 ± 1208 minutes; P = 0.036), and less FFP administered (PCC: 1.3 ± 1.0 vs control:3.3 ± 1.5; P < 0.001). PCC patients had a decreased incidence of progression of their ICH (PCC: 17.2% vs control: 44.2%; P = 0.031). Rapid reversal of coagulopathy in geriatric patients on warfarin is vital to limit the extent of ICH. PCC allows a much more rapid reversal than standard treatment with only FFP and vitamin K. Adopting such a protocol is associated not only with a more rapid reversal and less FFP use, but also less patients went on to extend their head bleeds.

Topics: Aged; Anticoagulants; Blood Coagulation Disorders; Blood Coagulation Factors; Craniocerebral Trauma; Female; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Pennsylvania; Retrospective Studies; Trauma Centers; Warfarin

What is the prevalence of immediate and incidence of delayed intracranial hemorrhage in patients with blunt head trauma who use warfarin or clopidogrel?. Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-8.e7.. To assess the prevalence of immediate and the cumulative incidence of delayed traumatic intracranial hemorrhage in patients using warfarin or clopidogrel.

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Intracranial Hemorrhages; Male; Platelet Aggregation Inhibitors; Ticlopidine; Warfarin

Elderly Americans are at increased risk of head trauma, particularly fall related. The effect of warfarin on head trauma outcomes remains controversial.. Medicare beneficiaries with head injuries from 2009 to 2011 were identified by International Classification of Diseases (ICD)-9 code. Preinjury warfarin use was determined using Part D claims. Multiple logistic regression models determined the association of preinjury warfarin on need for hospitalization, intensive care unit care, and occurrence of intracranial hemorrhage. Association between warfarin and in-hospital mortality was assessed using a Cox proportional hazard model.. Of 11,078 head injured patients, 5.2% were injured while on warfarin. Preinjury warfarin increased the odds of intracranial hemorrhage by 40% and doubled the risk of 30-day in-hospital mortality after adjusting for demographic and clinical factors.. Warfarin at the time of head injury increases the risk of adverse outcomes in Medicare beneficiaries with head injuries. Caution should be used when initiating anticoagulation in elderly Americans at risk for trauma.

Topics: Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Female; Follow-Up Studies; Humans; Incidence; Inpatients; Insurance Benefits; Intensive Care Units; Intracranial Hemorrhages; Male; Medicare; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Survival Rate; Thromboembolism; United States; Warfarin

Appropriate use of cranial computed tomography (CT) scanning in patients with mild blunt head trauma and preinjury anticoagulant or antiplatelet use is unknown. The objectives of this study were: 1) to identify risk factors for immediate traumatic intracranial hemorrhage (tICH) in patients with mild head trauma and preinjury warfarin or clopidogrel use and 2) to derive a clinical prediction rule to identify patients at low risk for immediate tICH.. This was a prospective, observational study at two trauma centers and four community hospitals that enrolled adult emergency department (ED) patients with mild blunt head trauma (initial ED Glasgow Coma Scale [GCS] score 13 to 15) and preinjury warfarin or clopidogrel use. The primary outcome measure was immediate tICH, defined as the presence of ICH or contusion on the initial cranial CT. Risk for immediate tICH was analyzed in 11 independent predictor variables. Clinical prediction rules were derived with both binary recursive partitioning and multivariable logistic regression.. A total of 982 patients with a mean (± standard deviation [SD]) age of 75.4 (±12.6) years were included in the analysis. Sixty patients (6.1%; 95% confidence interval [CI] = 4.7% to 7.8%) had immediate tICH. History of vomiting (relative risk [RR] = 3.53; 95% CI = 1.80 to 6.94), abnormal mental status (RR = 2.85; 95% CI = 1.65 to 4.92), clopidogrel use (RR = 2.52; 95% CI = 1.55 to 4.10), and headache (RR = 1.81; 95% CI = 1.11 to 2.96) were associated with an increased risk for immediate tICH. Both binary recursive partitioning and multivariable logistic regression were unable to derive a clinical prediction model that identified a subset of patients at low risk for immediate tICH.. While several risk factors for immediate tICH were identified, the authors were unable to identify a subset of patients with mild head trauma and preinjury warfarin or clopidogrel use who are at low risk for immediate tICH. Thus, the recommendation is for urgent and liberal cranial CT imaging in this patient population, even in the absence of clinical findings.

Topics: Aged; Aged, 80 and over; Anticoagulants; Clopidogrel; Craniocerebral Trauma; Female; Humans; Incidence; Intracranial Hemorrhage, Traumatic; Male; Middle Aged; Platelet Aggregation Inhibitors; Prevalence; Prospective Studies; Risk Factors; Ticlopidine; Tomography, X-Ray Computed; Warfarin

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Male; Warfarin

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Male; Warfarin

The direct thrombin inhibitor dabigatran has recently been approved in the US as an alternative to warfarin. The lack of guidelines, protocols, and an established specific antidote to reverse the anticoagulation effect of dabigatran potentially increases the rates of morbidity and mortality in patients with closed head injury (CHI). Confronted with this new problem, the authors reviewed their initial clinical experience.. The authors retrospectively reviewed all cases of adult patients (age ≥ 18 years) who sustained CHI secondary to ground-level falls and who presented to the authors' provisional regional Level I trauma center between February 2011 and May 2011. The authors divided these patients into 3 groups based on anticoagulant therapy: dabigatran, warfarin, and no anticoagulants.. Between February 2011 and May 2011, CHIs from ground-level falls were sustained by 5 patients while on dabigatran, by 15 patients on warfarin, and by 25 patients who were not on anticoagulants. The treatment of the patients on dabigatran at the authors' institution had great diversity. Repeat CT scans obtained during reversal showed 4 of 5 patients with new or expanded hemorrhages in the dabigatran group, whereas the warfarin group had 3 of 15 (p = 0.03). The overall mortality rate for patients sustaining CHI on dabigatran was 2 (40%) of 5, whereas that of the warfarin group was 0 (0%) of 15 (p = 0.05).. It is critical for physicians involved in the care of patients with CHI on dabigatran to be aware of an elevated mortality rate if no treatment protocol or guideline is in place. The authors will soon implement a reversal management protocol for patients with CHI on dabigatran at their institution in an attempt to improve efficacy and safety in their treatment approach.

Topics: Accidental Falls; Adult; Aged; Aged, 80 and over; Anticoagulants; Benzimidazoles; beta-Alanine; Cerebral Hemorrhage, Traumatic; Clinical Protocols; Craniocerebral Trauma; Dabigatran; Female; Humans; Male; Middle Aged; Retrospective Studies; Tomography, X-Ray Computed; Treatment Outcome; Warfarin; Young Adult

This study compares clinical outcomes in patients with head trauma, taking preinjury antiplatelet drugs (aspirin, clopidogrel) and anticoagulants (warfarin).. A prospective observational cohort study of prognosis in head-injured patients was undertaken in the emergency (ED) department of an adult tertiary hospital with a statewide neurosurgical service from 2008 to 2010. A convenience sample of patients taking warfarin, aspirin, clopidogrel or mixed therapy presenting to the ED with head trauma were included and followed-up over 3-18 months. Outcomes were severity of brain injury on neuroimaging, intensive care unit admission, intracranial surgery, intracranial complications, death in hospital, altered Glasgow Coma Score (GCS) on hospital discharge, and mortality and function scores on follow-up.. Overall, 345 patients were included in the study. Of these, 164, 70, 55 and 56 were taking aspirin, warfarin, clopidogrel and combination agents, respectively, with 250 having neuroimaging in the ED. Neuroimaging was significantly more likely to be undertaken in patients with a more urgent triage score (p<0.001), an abnormal GCS (p=0.004), older patients (p=0.039), and those taking warfarin (p<0.001). In patients receiving neuroimaging and admitted to hospital, the proportion with acute brain injury, poor hospital outcomes or overall poor outcomes were not statistically different between the agent groups.. A high proportion of patients taking warfarin underwent neuroimaging, but brain injury and admission rates were comparable between groups. There were no significant differences in short-term outcomes between the groups. The overall mortality is higher for patients on antiplatelet agents than warfarin.

Topics: Aged; Aged, 80 and over; Aspirin; Australia; Clopidogrel; Craniocerebral Trauma; Drug Therapy, Combination; Emergency Service, Hospital; Female; Fibrinolytic Agents; Glasgow Coma Scale; Hospital Mortality; Humans; Intensive Care Units; Male; Outcome Assessment, Health Care; Prospective Studies; Ticlopidine; Warfarin

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Intracranial Hemorrhages; Male; Platelet Aggregation Inhibitors; Ticlopidine; Warfarin

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Intracranial Hemorrhages; Male; Platelet Aggregation Inhibitors; Ticlopidine; Warfarin

Patients receiving warfarin who experience minor head injury are at risk of intracranial hemorrhage, and optimal management after a single head computed tomography (CT) scan is unclear. We evaluate a protocol of 24-hour observation followed by a second head CT scan.. In this prospective case series, we enrolled consecutive patients receiving warfarin and showing no intracranial lesions on a first CT scan after minor head injury treated at a Level II trauma center. We implemented a structured clinical pathway, including 24-hour observation and a CT scan performed before discharge. We then evaluated the frequency of death, admission, neurosurgery, and delayed intracranial hemorrhage.. We enrolled and observed 97 consecutive patients. Ten refused the second CT scan and were well during 30-day follow-up. Repeated CT scanning in the remaining 87 patients revealed a new hemorrhage lesion in 5 (6%), with 3 subsequently hospitalized and 1 receiving craniotomy. Two patients discharged after completing the study protocol with 2 negative CT scan results were admitted 2 and 8 days later with symptomatic subdural hematomas; neither received surgery. Two of the 5 patients with delayed bleeding at 24 hours had an initial international normalized ratio greater than 3.0, as did both patients with delayed bleeding beyond 24 hours. The relative risk of delayed hemorrhage with an initial international normalized ratio greater than 3.0 was 14 (95% confidence interval 4 to 49).. For patients receiving warfarin who experience minor head injury and have a negative initial head CT scan result, a protocol of 24-hour observation followed by a second CT scan will identify most occurrences of delayed bleeding. An initial international normalized ratio greater than 3 suggests higher risk.

Topics: Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Critical Pathways; Female; Humans; Intracranial Hemorrhages; Male; Middle Aged; Prospective Studies; Time Factors; Tomography, X-Ray Computed; Trauma Centers; Warfarin; Watchful Waiting

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Male; Warfarin

Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage in these patients, however, are unknown. The objective of this study is to address these gaps in knowledge.. A prospective, observational study at 2 trauma centers and 4 community hospitals enrolled emergency department (ED) patients with blunt head trauma and preinjury warfarin or clopidogrel use from April 2009 through January 2011. Patients were followed for 2 weeks. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage were calculated from patients who received initial cranial computed tomography (CT) in the ED. Delayed traumatic intracranial hemorrhage was defined as traumatic intracranial hemorrhage within 2 weeks after an initially normal CT scan result and in the absence of repeated head trauma.. A total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%) from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics, although concomitant aspirin use was more prevalent among patients receiving clopidogrel. The prevalence of immediate traumatic intracranial hemorrhage was higher in patients receiving clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients receiving clopidogrel.. Although there may be unmeasured confounders that limit intergroup comparison, patients receiving clopidogrel have a significantly higher prevalence of immediate traumatic intracranial hemorrhage compared with patients receiving warfarin. Delayed traumatic intracranial hemorrhage is rare and occurred only in patients receiving warfarin. Discharging patients receiving anticoagulant or antiplatelet medications from the ED after a normal cranial CT scan result is reasonable, but appropriate instructions are required because delayed traumatic intracranial hemorrhage may occur.

Topics: Aged; Aged, 80 and over; Anticoagulants; Clopidogrel; Craniocerebral Trauma; Emergency Service, Hospital; Female; Humans; Intracranial Hemorrhages; Male; Middle Aged; Platelet Aggregation Inhibitors; Prospective Studies; Risk; Ticlopidine; Time Factors; Tomography, X-Ray Computed; Warfarin

Topics: Anticoagulants; Clopidogrel; Craniocerebral Trauma; Female; Humans; Intracranial Hemorrhages; Male; Platelet Aggregation Inhibitors; Ticlopidine; Warfarin

We report the first case of acute subdural hematoma (SDH) developing after tightening the halo of an osteoporotic 61-year-old woman on warfarin therapy for bilateral traumatic vertebral artery dissection. We discuss literature relevant to this case with an emphasis on identifying warning signs, including recurrent pin loosening, especially in patients with compromised bone structure and high risk of bleeding. Our 61-year-old patient presented to neurosurgery clinic for a 2-month follow-up of a type-III odontoid fracture sustained in a motor vehicle accident. The patient had repeatedly loosened halo pins, and shortly after the pins were tightened, the patient had a syncopal event and struck her head. An emergent computed tomography scan revealed acute SDH requiring emergent craniotomy and evacuation. SDH following pin penetration in a patient with bilateral vertebral artery dissection, osteoporosis, and anticoagulation has not been reported as a complication of the use of the halo vest for stabilization of the cervical spine. The risk of this serious complication can be minimized by giving special consideration to patients with comorbidities and by repositioning problematic pins. This case demonstrates the importance of special attention to bone strength, bleeding risk, and recurrent minor complaints with use of the halo vest.

Topics: Accidental Falls; Accidents, Traffic; Anticoagulants; Bone Nails; Craniocerebral Trauma; Craniotomy; Device Removal; Equipment Failure; Female; Hematoma, Subdural, Acute; Hemorrhagic Disorders; Humans; Immobilization; Middle Aged; Odontoid Process; Osteoporosis, Postmenopausal; Risk Factors; Spinal Fractures; Syncope; Tomography, X-Ray Computed; Vertebral Artery Dissection; Warfarin

Topics: Anticoagulants; Craniocerebral Trauma; Female; Humans; Male; Warfarin

The yield of head computed tomography (CT) for patients who suffered head trauma with a presenting Glasgow Coma Scale (GCS) score of 15 has been reported to be low, even in patients who are anticoagulated or on antiplatelet therapy. We undertook this study to (1) determine the frequency of intracranial hemorrhage in anticoagulated patients and patients on antiplatelet therapy and its impact on clinical management, (2) identify predictors of positive imaging findings, and (3) assess potential differences between anticoagulation and antiplatelet therapy.. We conducted a retrospective review of the trauma registry at our institution, a Level II trauma center. All trauma registry patients with a minor head injury registered between the years 2004 and 2006 who were taking warfarin or clopidogrel, had a presenting GCS score of 15, and underwent head CT were included in this study. Intracranial hemorrhage on head CT was considered a positive result.. One hundred forty-one patients (male, n=67; female, n=74), mean age 79 years (range, 36-101 years), were included in this study. Forty-one patients (29%) were diagnosed with intracranial hemorrhage. Thirty-nine (95%) of these 41 patients underwent reversal and/or discontinuation of clopidogrel and/or warfarin. Five patients required surgical evacuation of an intracranial hemorrhage. Four patients died. Loss of consciousness (Wald=7.468, β=1.179, p=0.008) predicted a positive CT result. Type of medication (warfarin, aspirin, or clopidogrel) did not reach statistical significance as a predictor of positive result.. Despite a presenting GCS score of 15, patients with minor head injury from the trauma registry at our institution taking anticoagulation or antiplatelet therapy have a high incidence of intracranial hemorrhage especially after reported loss of consciousness.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Clopidogrel; Craniocerebral Trauma; Female; Glasgow Coma Scale; Humans; Incidence; Intracranial Hemorrhage, Traumatic; Male; Massachusetts; Middle Aged; Platelet Aggregation Inhibitors; Retrospective Studies; Ticlopidine; Tomography, X-Ray Computed; Trauma Centers; Warfarin

Topics: Anticoagulants; Clopidogrel; Craniocerebral Trauma; Glasgow Coma Scale; Humans; International Normalized Ratio; Intracranial Hemorrhage, Traumatic; Partial Thromboplastin Time; Platelet Aggregation Inhibitors; Risk Factors; Ticlopidine; Tomography, X-Ray Computed; Warfarin

Head injury represents one of the most important and frequent traumatic pathology in the emergency department. Among the different risk factors, preinjury use of warfarin has received considerable attention in trauma literature. The aim of this study was to identify further risk indicators of intracranial hemorrhage (ICH) to improve risk stratification of warfarinized patients with minor head injuries.. Medical records of 1,554 adult patients with minor head injuries evaluated by the Emergency Department of Azienda Ospedaliera, Universitaria Careggi from January 2007 to February 2008 were analyzed retrospectively. All the patients included in the study were subjected to blood tests. The international normalized ratio (INR) measured on admission was correlated with the results of head computed tomography scan.. Of the 1,410 patients included in the study, 75 (5.2%) were warfarin anticoagulated at the time of trauma. The INR measured on admission was 2.37 ± 1.04 (mean ± standard deviation), and this value was significantly associated with occurrence of ICH after head trauma (r = 0.37; p < 0.005). For 12 (of 75) patients of this group, the findings of the computed tomography scans were positive. The receiver operating characteristic curve show that the most effective INR cutoff value was 2.43, with a sensitivity of 92%, a specificity of 66%, and positive and negative predictive values of 33% and 97%, respectively.. This study highlights the strong relationship between INR values and the probability of ICH, as shown in previous studies. The high negative predictive value of the identified cutoff, if confirmed, could be used to exclude ICH.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Emergency Service, Hospital; Female; Follow-Up Studies; Humans; Incidence; Intracranial Hemorrhages; Italy; Male; Middle Aged; Prognosis; Retrospective Studies; Risk Factors; Thrombosis; Tomography, X-Ray Computed; Warfarin

Conflicting evidence exists surrounding the increased risk of adverse outcome conferred by preinjury anticoagulant and antiplatelet treatment in patients with head injury. The aim of this study was to determine the epidemiology of patients with head injury on anticoagulant and antiplatelet treatment admitted to a hospital from an emergency department (ED).. This was a retrospective analysis of all patients with head injury admitted to a hospital from a major UK ED between 1 January 2005 and 31 December 2007.. 399 patients met the inclusion criteria. 110 patients underwent CT, with 24 having traumatic haemorrhage. Of 271 patients on aspirin, 75 (28%) underwent CT, with 19 of these (25%) having traumatic haemorrhage. Of 89 patients on warfarin, 27 (30%) underwent CT, with 4 of these (15%) having traumatic haemorrhage. Seven of the 24 (29%) patients with traumatic haemorrhage on CT did not undergo urgent ED scanning. All these patients were on aspirin.. This study confirms the need for caution in the early discharge of patients with head injury taking anticoagulant medication. This study also raises concerns that patients taking antiplatelet medication prior to injury may also be at high risk of developing covert serious intracranial haemorrhage and suggests the need for a well-designed cohort study looking at antiplatelet risk in head injury.

Topics: Adult; Age Distribution; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Craniocerebral Trauma; Emergency Service, Hospital; Female; Hospitalization; Humans; Intracranial Hemorrhages; Male; Middle Aged; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Retrospective Studies; Tomography, X-Ray Computed; Warfarin

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Cardiovascular Diseases; Cohort Studies; Craniocerebral Trauma; Female; Glasgow Coma Scale; Humans; Length of Stay; Male; Outcome Assessment, Health Care; Retrospective Studies; Warfarin

We hereby describe a 42-year-old lady who developed vertebral artery dissection following a head injury. The clinical features and management of the condition are discussed.

Topics: Adult; Amlodipine; Anticoagulants; Antihypertensive Agents; Aspirin; Craniocerebral Trauma; Female; Hemianopsia; Humans; Hypertension; Magnetic Resonance Angiography; Stroke; Tomography, X-Ray Computed; Vertebral Artery Dissection; Warfarin

A large population of patients on oral anticoagulants is exposed to the risk of traumatic brain injury (TBI). Effects of age and anticoagulation on TBI outcomes need to be assessed separately.. Retrospective analysis of consecutive series of TBI patients (age 18 years and older) in a suburban teaching hospital.. A total of 1,493 adult blunt head trauma patients between January 2001 and May 2005 were analyzed. Of these, 159 patients were warfarin-anticoagulated at the time of trauma. The mortality in anticoagulated patients was statistically significantly higher than in the control group (38/159, 23.9% vs. 66/1,334, 4.9%; p < 0.001; odds ratio 6.0). Mortality of patients over 70 years of age was significantly higher than in the younger population (p < 0.001). Both mortality and the occurrence of intracranial hemorrhage (ICH) after head trauma were significantly increased with higher INR (Cochran's linear trend p < 0.001), especially with INR over 4.0 (mortality 50%, risk of ICH 75%). Preinjury warfarin anticoagulation and age were found to be predictive of survival in a binary logistic regression model (92.5% correct prediction, p = 0.027). Addition of Injury Severity Score and initial Glasgow Coma Score to this model only modestly improved its predictive performance (95.4% correct prediction, p < 0.001).. Both age and warfarin anticoagulation are independent predictors of mortality after blunt TBI. Warfarin anticoagulation carries a six-fold increase in TBI mortality. Age over 70 years and excessive anticoagulation are associated with higher mortality, as well.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Craniocerebral Trauma; Humans; Intracranial Hemorrhages; Middle Aged; Regression Analysis; Retrospective Studies; Risk Factors; United States; Warfarin; Wounds, Nonpenetrating

The objective of this study was to study the clinical course and outcome of warfarinised patients who were hospitalised because of head trauma.. 13 patients (ten males and three females; median age 69 years) who presented to the Royal Perth Hospital, Australia and who had suffered a head injury between July 1994 and June 2000 while concurrently taking warfarin, were studied.. Confusion was the commonest presenting symptom (four patients). Five patients presented after more than 24 hours of the injury. Eight patients were anticoagulated for thromboembolic disease and five for atrial fibrillation. The patients had a median injury severity score of 25 (range 1-43). The median international normalised ratio was 2.4 (range 1.8-10) on admission and 1.8 (range 1.0-10) on discharge. 11 of the 13 patients had computed tomography of the head. Intracerebral bleeding was the commonest injury (nine patients). The median length of hospital stay was six days (range 3-30). Five patients died (38.5%).. Warfarinised patients who sustain minor head trauma should be hospitalised for close neurological observation and should have a low threshold for performing computed tomography.

Topics: Accidental Falls; Accidents, Traffic; Aged; Aged, 80 and over; Anticoagulants; Cerebral Hemorrhage; Confusion; Craniocerebral Trauma; Female; Glasgow Coma Scale; Humans; Male; Middle Aged; Retrospective Studies; Risk Assessment; Risk Factors; Warfarin

Head CT is frequently ordered for trauma patients who are receiving anticoagulation. However, whether patients with a Glasgow Coma Scale (GCS) score of 15 and normal findings on neurologic examination require CT is still debated. The purpose of our study was to assess the use of cranial CT in patients receiving anticoagulants after head trauma and to establish clinical criteria to identify those in this group who do not need emergency CT.. We retrospectively reviewed patients receiving heparin or coumadin who had head trauma and who subsequently underwent cranial CT at a level I trauma center within a 4-year period. Patients were evaluated for mechanism of injury, clinical signs and symptoms of head injury, and type and reason for anticoagulation. Prothrombin time, international normalized ratio, partial thromboplastin time, GCS score, age, and head CT results were recorded for each patient.. A total of 89 patients fulfilled the enrollment criteria. Among them, 82 had no evidence of intracranial injury on CT. Seven patients had evidence of intracranial hemorrhage. Patients without hemorrhage had no significant focal neurologic deficits and presented with an average GCS score of 14.8. Patients with intracranial hemorrhage tended to have focal neurologic deficits and presented with an average GCS score of 12.0.. Patients with head injury, normal GCS scores, and no focal neurologic deficits and who are receiving the anticoagulants heparin or coumadin may not necessarily require emergency CT.

Topics: Aged; Aged, 80 and over; Anticoagulants; Cerebral Hemorrhage; Craniocerebral Trauma; Female; Glasgow Coma Scale; Heparin; Humans; Male; Nervous System Diseases; Retrospective Studies; Tomography, X-Ray Computed; Warfarin

This study aimed to determine the impact of warfarin use on the severity of injury among elderly patients presenting with closed head injuries.. A cohort of patients 55 years of age or older with closed head injuries taken to a tertiary trauma center between April 1993 and March 2001 was retrospectively identified. Patient characteristics, mechanism of injury, type and severity of injury, and hospital survival data were obtained from the trauma registry. Each case then was reviewed for completeness of information, assessment of preinjury warfarin use, and comorbidity.. Among the 384 patients presenting with closed head injuries, 35 (9%) were receiving warfarin before their trauma. As compared with nonusers, anticoagulated patients had a higher frequency of isolated head trauma (54% vs. 32%; p = 0.008), more severe head injuries (65.7% vs. 44.1%; p = 0.02), and a higher rate of mortality (40% vs. 21%, p = 0.01). These associations remained evident even after population differences in age, gender, comorbidities, and mechanism of injury were taken into account. Indeed, according to multivariate logistic regression models, warfarin use was associated with a statistically significant risk of death (odds ratio [OR], 2.73; 95% confidence interval [CI], 1.22-6.12), statistically significant odds for more severe head injury (OR, 2.39; 95% CI, 1.10-5.17), and odds for isolated head injury that almost reached statistical significance (OR, 1.79; 95% CI, 0.82-3.90).. Among patients 55 years of age or older who present with closed head injury, the use of warfarin before trauma appears to be associated with a higher frequency of isolated head trauma, more severe head trauma, and a higher likelihood of death. The findings of this retrospective study support the concern about the adverse effects of anticoagulants in cases of head trauma.

Topics: Aged; Aged, 80 and over; Anticoagulants; Comorbidity; Craniocerebral Trauma; Female; Glasgow Coma Scale; Humans; Injury Severity Score; Male; Middle Aged; Retrospective Studies; Trauma Centers; Treatment Outcome; Warfarin

We present the case of a young male with severe head injury, cervico-thoracic fractures, and an initially unrecognized brainstem infarct due to unilateral dissection of vertebral artery, who made an unusually excellent recovery. This report stresses the importance of prompt clinico-imaging diagnosis and prophylactic anticoagulant treatment in such cases.

Topics: Accidents, Traffic; Adult; Anticoagulants; Brain Stem Infarctions; Cervical Vertebrae; Craniocerebral Trauma; Early Diagnosis; Humans; Magnetic Resonance Imaging; Male; Motorcycles; Thoracic Vertebrae; Treatment Outcome; Vertebral Artery Dissection; Warfarin

The frequency of use of warfarin anticoagulation increases significantly in the elderly population. It remains controversial whether this puts these patients at increased risk for hemorrhagic complications after trauma.. We prospectively evaluated consecutive trauma patients who were taking warfarin and compared their outcomes to a group of age-matched patients with head injuries but not taking warfarin.. One hundred fifty-nine trauma patients on warfarin were evaluated, 94 (59%) with some type of head trauma; 25 of these 94 patients (27%) had documented intracranial trauma. Fifteen patients died (9.4%); they had an international normalized ratio of 3.3 +/- 1.6 versus 3.0 +/- 2.1 for survivors in the warfarin group (p = 0.585). Twelve deaths were in the group of 25 patients with intracranial injuries (48%). Three patients without head injury died (5%) of other causes not related to warfarin or hemorrhage at a mean of 13 days after admission. Ten of 12 patients on warfarin with intracranial injuries who died had documented loss of consciousness (LOC); two patients who died secondary to an isolated intracranial injury had no LOC. Of 70 age-matched patients with head trauma not taking warfarin, 47 (67%) had intracranial injury and 5 of these died (10%) (p < 0.001 for both values compared with study patients). There were no significant differences for patients with intracranial injury comparing those on warfarin and those who were not in terms of age, gender, mechanism of injury, Injury Severity Score, or Glasgow Come Scale score.. We conclude that the preinjury use of warfarin does not place the trauma patient at increased risk for fatal hemorrhagic complications in the absence of head trauma. Furthermore, the presence of a head trauma alone is not predictive of mortality. However, the presence of intracranial injury is strongly associated with a mortality rate that is significantly higher than patients with head trauma who are not taking warfarin. LOC is also associated with mortality, but the absence of loss of consciousness does not reliably indicate the absence of intracranial injury or risk of death.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Female; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Prospective Studies; Warfarin

We studied intracranial damage in patients with mild head injuries who were taking warfarin. Of the 215,785 individuals who visited the Mount Auburn and Beth Israel accident and emergency departments during our study, we identified records for 144 patients by anticoagulation status and computed tomography (CT) imaging. We retrospectively reviewed these patients and ten (7%, 95% CI 3-11) with clinically important injuries on cranial CT. Our findings suggest that patients with head injuries who receive anticoagulants have a similar or greater risk of intracranlal injury to those falling into a previously defined moderate-risk category, invalidating a previous conclusion that CT scanning is unnecessary in such patients.

Topics: Aged; Aged, 80 and over; Anticoagulants; Craniocerebral Trauma; Female; Humans; Intracranial Hemorrhages; Male; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed; Warfarin

Topics: Aged; Anticoagulants; Craniocerebral Trauma; Emergency Medical Services; Humans; Intracranial Hemorrhages; Male; Tomography, X-Ray Computed; Warfarin

Warfarin is the most common oral anticoagulant used for chronic anticoagulation therapy. Even without any antecedent trauma overanticoagulation can result in intracranial hemorrhage. The triad of anticoagulation with warfarin, age greater than 65 years, and traumatic head injury frequently produces a lethal brain hemorrhage. A retrospective review of more than 2000 patients admitted to the Trauma Service between September 1998 and May 2000 produced 278 patients with head injury and CT-documented intracranial hemorrhage. Of these patients 21 were admitted with an elevated prothrombin time (PT) due to anticoagulation with warfarin. Eighteen patients (86%) were above the age of 70. The most common indications for anticoagulation were atrial fibrillation (71%), deep venous thrombosis (19%), aortic valve replacement (9%), and ischemic cerebral infarcts (9%). Fourteen injuries were the result of a fall, one resulted from a gunshot wound, and one resulted from an assault. The remaining five patients were excluded as their history, workup, and evaluation by neurosurgery suggested a spontaneous bleed leading to fall rather than a fall causing a traumatic bleed. The average Glasgow Coma Score on admission was 11. The average PT and International Normalized Ratio (INR) on admission were 19.2 and 2.99 respectively. Eight of the 16 patients analyzed died. The risk of intracranial hemorrhage with relatively minor head injury is increased dramatically in the anticoagulated patient. A mortality rate of 50 per cent far exceeds the mortality rate in patients with similar head injuries who are not anticoagulated. In addition the risk/benefit equation of anticoagulation for the elderly is more complex and differs from that for younger patients. Perhaps more frequent and judicious monitoring of prothrombin time levels with lower therapeutic ranges (INR 1.5-2) is necessary.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Craniocerebral Trauma; Female; Glasgow Coma Scale; Humans; Intracranial Hemorrhages; Male; Retrospective Studies; Venous Thrombosis; Warfarin

The objective of this study was to determine whether the preinjury condition of anticoagulation had an adverse impact on patients sustaining injury.. A retrospective analysis was performed for prospectively collected registry data from 1995-2000 from all accredited trauma centers in Pennsylvania. The registry was queried for all trauma patients who had anticoagulation therapy as a preinjury condition (PIC). This group served as our experimental cohort. A control cohort (not having warfarin therapy as a PIC) was developed using case-matching techniques for age, sex, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), A Severity Characterization of Trauma (ASCOT) score, and in the head injured patients, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses. Head and non-head injured patients were evaluated separately. The cohorts were examined for 28-day mortality, intensive care unit length of stay (ICU-LOS), hospital length of stay (HOS-LOS), PICs, occurrences, discharge destinations, and functional status at discharge. Chi2 and Student's t test were used to evaluate the data; p values < 0.05 were considered significant.. Two thousand nine hundred forty-two patients were available for analysis. The prevalence of PICs was significantly greater in the warfarin group for both the head and non-head injured populations (p < 0.003 and p < 0.0001, respectively). The incidence of occurrences in the non-head injured population was statistically higher for the warfarin patients (p < 0.001), but showed no difference in the head injured group regardless of warfarin use (p = 0.15). Functional status at discharge demonstrated no clinically significant difference between the warfarin and non-warfarin groups in both head and non-head injured populations. There was no difference in discharge destination in the head injured population; however, in the non-head injured population a greater percentage of non-warfarin patients was discharged to home when compared with the warfarin patients.. Our data suggest that the PIC of anticoagulation with warfarin does not adversely impact mortality or LOS outcomes in both head and non-head injured patients. In non-head injured patients, however, the occurrence rates and discharge destination were different. More research needs to be done to determine whether this is related to anticoagulation or other reasons (i.e., number of PICs). These data should be used when weighing risk/benefit ratios of prescribing chronic anticoagulation.

Topics: Aged; Anticoagulants; Case-Control Studies; Cohort Studies; Craniocerebral Trauma; Female; Humans; Injury Severity Score; Length of Stay; Male; Patient Discharge; Pennsylvania; Prospective Studies; Registries; Retrospective Studies; Trauma Centers; Warfarin; Wounds and Injuries

The risk factors affecting intracranial haemorrhage in warfarinised patients are described and an attempt made to calculate the risk of haemorrhage in warfarinised patients with minor head injuries. Using the data from studies of patients with spontaneous haemorrhage while taking warfarin, guidelines for treatment and given and the likely outcome predicted.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Cerebral Hemorrhage; Craniocerebral Trauma; Emergency Service, Hospital; Female; Humans; Injury Severity Score; Male; Middle Aged; Prevalence; Prognosis; Risk Assessment; Survival Rate; Thromboembolism; Tomography, X-Ray Computed; United Kingdom; Warfarin

Two cases of patients on warfarin who developed intracranial haematoma after an apparently minor head injury are described. There is a 10-fold increase in the likelihood of developing an intracranial haematoma in these patients. Recommendations are made regarding the management of this type of patient seen in the accident and emergency department.

Topics: Aged; Anticoagulants; Cerebral Hemorrhage; Craniocerebral Trauma; Emergency Service, Hospital; Female; Heart Diseases; Humans; Male; Risk Factors; Warfarin

The incidence of deep vein thrombosis (DVT) in the disabled pediatric population has rarely been studied. The purpose of our retrospective study was to define the incidence in patients younger than 18 years of age who were in a rehabilitation center. We reviewed the charts of 532 children admitted to the center from 1983 through 1987, and found a 2.2% overall incidence of DVT. The largest group of children under 18 of age with documented or suspected DVT was the group with spinal cord injuries (SCI). There were 87 SCI children, 67 of whom were between the ages of 15 and 18. Of the 67, 7 (10%) had DVT: 1 of the 20 SCI children under age 15 had DVT. There were single cases of DVT documented in children with: meningoencephalitis, arteriovenous malformation, closed head injuries, and Guillian-Barré syndrome. We studied the risk involved in treating DVT with heparin and formulated recommendations based on our findings.

Topics: Adolescent; Age Factors; Arteriovenous Malformations; Child; Child, Preschool; Craniocerebral Trauma; Disabled Persons; Drug Therapy, Combination; Female; Heparin; Humans; Incidence; Male; Meningoencephalitis; Polyradiculoneuropathy; Puberty; Rehabilitation Centers; Retrospective Studies; Risk Factors; Thrombophlebitis; Warfarin

Inherited protein S deficiency has been associated with an increased risk of thromboembolic disease. It is possible that such a coagulopathy could predispose children to the development of strokes by permitting clot formation in response to stimuli that ordinarily would be insufficient to cause thrombus formation.. We evaluated a previously well 4-year-old boy who developed cerebral venous thrombosis after suffering minor head trauma. Crossed-immunoelectrophoresis of his plasma showed a marked decrease of the free, active form of protein S. Family studies revealed that the patient's father and other paternal relatives had a similar abnormality of protein S.. We suggest that the cerebral venous thrombosis in this child was initially precipitated by minor head trauma and pathological thrombus formation was then potentiated by inherited protein S deficiency. This case extends the clinical spectrum for protein S deficiency and emphasizes the importance of evaluating family members to establish a specific diagnosis and therapeutic intervention.

Topics: Blood Coagulation; Child, Preschool; Craniocerebral Trauma; Humans; Immunoelectrophoresis, Two-Dimensional; Magnetic Resonance Imaging; Male; Protein S; Protein S Deficiency; Sinus Thrombosis, Intracranial; Warfarin