Risk Of Delayed Intracranial Hemorrhage in Anticoagulated Patients With Mild Traumatic Brain Injury

Systematic Review and Meta-Analysis

Jean-Marc Chauny, MD, MSC; Martin Marquis, MSC; Francis Bernard, MD; David Williamson, BPHARM, PHD; Martin Albert, MD; Mathieu Laroche, MD, MSC; Raoul Daoust, MD, MSC

Disclosures

J Emerg Med. 2016;51(5):519-528.

Conclusions

The aim of this meta-analysis was to assess the risk of delayed intracerebral bleeding in patients suffering a mild traumatic brain injury who have been anticoagulated with vitamin K antagonist before injury. We found that the incidence of delayed bleeding in patients with an initially normal head scan was very low at 0.6%. Furthermore, 85% of the patients with delayed hemorrhage did not require clinical intervention, reducing even further the risk of significant outcomes to 0.13%. This risk is sufficiently low to justify discharging the patients after the initial evaluation by a physician when the first scan is negative.

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Table 1. Summary of Included Studies
First Author	Design	Study Setting	Patients Analyzed, n	Patients with Delayed ICH within 24 h, n (%)	Notes	Patients' Secondary Outcomes
Kaen (31)	Prospective	Madrid, Spain	137	2 (1.5)	Both patients on antiplatelet	Both discharged
Peck (28)	Retrospective	San Diego, CA	289	4 (1.4)	Second scan at 6 h	All 4 discharged, 1 suffering an unrelated death, without any ICH on autopsy
Menditto (27)	Prospective	Ancona, Italy	87	5 (6)	79% patients involved in high-velocity impact	4 discharged, 1 neurosurgery
Nishijima (29)	Prospective multicenter	Sacramento, CA	687	1 (0.15)	—	Discharged
Schoonman (30)	Retrospective	The Hague, Netherlands	211	1 (0.47)	—	Neurosurgery and died
Taylor (33)	Retrospective multicenter	Nambour, Australia	58	1 (1.7)	No mechanism of injury	No outcome
McCammack (32)	Retrospective	San Diego, CA	125	0	Second scan at 6 h	—

ICH = intracranial hemorrhage.

Table 2. Patient Population Characteristics from All Selected Papers*
First Author	Kaen (31)	Peck (28)	Menditto (27)	Nishijima (29)	Schoonman (30)	Taylor (33)	McCammack (32)
Year	2010	2011	2012	2012	2014	2012	2015
Design	Prospective	Retrospective	Prospective	Prospective	Retrospective	Retrospective	Retrospective
Site (n)	Single	Single TC I	Single TC II	Multiple (6)	Single TC I	Multiple (2)	Single
n/N (included/total)	137	289/424	87/97	687/768	211	58	125/144
Age (y), mean (SD)	76 (9)	75 (13.6)	82 (9)	75.3 (13)	77 (11.7)	79	73.8
Female, n (%)	92 (67)	214 (50.5)	55 (63.2)	406 (52.9)	114 (54)	76 (48)	77 (53.5)
GCS, mean (SD)	14.9 (0.3)	14.8 (0.9)	15 (0)	—	—	—	14.9
GCS = 15	122 (89)	—	87 (100)	674 (87.8)	—	—	—
GCS = 14	15 (11)	—	0	73 (10)	—	—	—
GCS = 13	0	—	0	—	—	—	—
GCS < 13	—	—	—	21 (2.7)	—	—	—
Headache, n (%)	34 (25)	—	3 (3)	239 (31.1)	—	—	—
Vomiting, n (%)	27 (20)	—	3 (3)	34 (4.4)	—	—	—
LOC, n (%)	14 (10)	131 (35.7)	16 (18)	136 (17.7)	—	—	38 (26.5)
Amnesia, n (%)	6 (4.3)	—	4 (5)	—	—	—	—
Seizure, n (%)	2 (1.7)	—	—	—	—	—	—
Scalp wound, n (%)	38 (28)	—	—	448 (61.8)	—	—	—
Focal deficit, n (%)	—	17 (4.0)	0	—	—	—	—
Fall, n (%)	122 (89)	357 (84.2)	18 (21)	644 (83.9)	155 (73.5)	—	—
Traffic accident, n (%)	7 (5)	38 (9)	69 (79)	32 (4.2)	25 (11.8)	—	—
Assault, n (%)	4 (3)	—	—	—	—	—	—
Direct impact, n (%)	2 (1.7)	—	—	45 (5.9)	8 (3.8)	—	—
Pedestrian struck, n (%)	2 (1.7)	—	—	4 (0.5)	—	—	—
Associated injury, n (%)	29 (21)	—	30 (34)	—	—	—	—
INR, mean (SD)	3.8 (1.2)	2.5 (1.2)	2.34	2.5	3.37 (1.46)	—	2.4
Concomitant antiplatelet, n (%)	3 (2.2)	25 (5.9)	0	19 (2.5)	—	5 (8.6)	—
ISS, mean (SD)	—	4.9 (3.7)	—	—	—	—	—
Delay (h) before second CT, mean (SD)	19.8	8.8 (10.2)	—	Variable	—	17.1	6

CT = computed tomography; GCS = Glasgow Coma Scale; INR = international normalized ratio; ISS = Injury Severity Score; LOC = loss of consciousness; SD = standard deviation; TC = trauma center.
*n (%) extracted directly from publications.

Table 3. Quality Assessment of All Included Studies Using the Newcastle-Ottawa Scale for Selection, Comparability, and Outcome
First Author	Selection (Maximum****)	Comparability (Maximum**)	Outcome (Maximum***)
Kaen (31)	***	**	***
Peck (28)	***	**	**
Menditto (27)	***	—	**
Nishijima (29)	***	**	***
Schoonman (30)	***	**	**
Taylor (33)	**	**	***
McCammack (32)	**	*	*

Table 4. Clinical Description of Patients with Delayed Intracranial Hemorrhage
First Author, Patients number	Co-Medication	Age (y)	Sex	INR	Mechanism	Time of First Scan	Outcome	Bleeding Description
Kaen (31), no. 1	ASA	67	M	3.10	Fall	2.5 h	Discharged	Minimal intraventricular hemorrhage
Kaen (31), no. 2	ASA	74	M	2.88	Fall	3.4 h	Discharged	Discrete subarachnoid hemorrhage over the convexity of the right hemisphere
Schoonman (30), no. 1	—	85	M	3.13	Fall	Within 12 h of trauma	Neurosurgery/died	Subdural hematoma
Nishijima (29), no. 1	—	63	M	1.50	Fall	During initial ED evaluation	Discharged	Small intraparenchymal contusion and subarachnoid hemorrhage
Peck (28), no. 1	ASA	86	M	2.2	Vehicle accident	NR	Discharged	Small tentorial subdural hemorrhage
Peck (28), no. 2	—	86	F	2.2	Fall	NR	Discharged	Equivocal: possible intraparenchymal hemorrhage
Peck (28), no. 3	ASA	80	M	3.9	Fall	NR	Discharged	Minimal subarachnoid hemorrhage
Peck (28), no. 4	—	89	M	1.7	Fall	NR	Unrelated death	Small hematoma
Menditto (27), no. 1	—	68	F	3.8	Accident	*	Discharged	Minimal intracranial bleeding
Menditto (27), no. 2	—	78	M	2.4	Accident	*	Neurosurgery	Intracranial bleeding
Menditto (27), no. 3	—	88	M	1.4	Syncope	*	Discharged	Intracranial bleeding
Menditto (27), no. 4	—	78	M	2.1	Syncope	*	Discharged	Minimal intracranial bleeding
Menditto (27), no. 5	—	87	F	3.3	Accident	*	Discharged	Intracranial bleeding
Taylor (33), no. 1	—	78	F	4.3	NR	NR	NR	NR

ASA = acetylsalicylic acid; ED = emergency department; F = female; INR = international normalized ratio; M = male; NR = not reported.
*Median time between head injury and initial computed tomography scan for the study of 4.5 h.

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Risk Of Delayed Intracranial Hemorrhage in Anticoagulated Patients With Mild Traumatic Brain Injury

Systematic Review and Meta-Analysis

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