Low Risk of Delayed Brain Bleed After Blunt Head Trauma in Older People on DOAC Therapy

By Reuters Staff

April 16, 2021

NEW YORK (Reuters Health) - There is a low risk of delayed intracranial hemorrhage (ICH) in older patients on direct oral anticoagulant (DOAC) therapy who fall and hit their head, according to a new study.

This finding calls into question the need to extended observation in the hospital or repeat head CT scan after an initial negative CT scan, the researchers say.

To evaluate the risk of delayed ICH after a normal CT scan in patients on DOACs who suffered blunt head trauma, Dr. Thaddeus Puzio with The University of Texas Medical Center in Houston and colleagues did a systematic review of the literature and meta-analysis.

They included 12 relevant studies (four prospective and eight retrospective) involving a total of 5,289 mostly elderly patients who suffered a ground-level fall. Of the total, 24% were on a DOAC when they fell and 34% were on warfarin; 104 patients were on concomitant anticoagulant and antiplatelet medications.

All 12 studies involved a period of hospital observation. Four studies reported obtaining repeat CT scans during the observation period on all patients while eight studies reported only repeating CT scans if symptoms were observed.

Overall, 25 patients on DOAC therapy and 44 on warfarin suffered delayed ICH and the rate of delayed ICH was "similarly low" in both groups (2.43% and 2.31%, respectively), the authors report in the Journal of the American College of Surgeons.

No patient on concomitant anticoagulant and antiplatelet medication suffered delayed ICH. There were 516 patients not on any anticoagulation included in one study, and two suffered delayed ICH (0.39%).

Based on these data, the researchers calculate that an additional 50 patients on DOAC therapy would need to be observed in order to detect one additional delayed ICH.

Two patients on DOAC and eight on warfarin died from complications after delayed ICH.

The low mortality rate prohibited calculation of a pooled rate, the researchers say, but the overall crude risk of death from delayed ICH among the DOAC and warfarin patients combined was 0.33% and was lower in patients on DOAC (0.16%) than in those on warfarin (0.45%).

Summing up, the study team says, "These estimates can be used as a starting point for discussions with patients without another indication for admission regarding observation in the hospital. Additionally, these numbers can guide trauma centers in determining their policies for patients with blunt head trauma on systemic anticoagulation."

SOURCE: https://bit.ly/3rF551G Journal of the American College of Surgeons, online March 22, 2021.