May 5, 2017

Risk of Intracranial Hemorrhage in Ground-Level Fall with Antiplatelet or Anticoagulant Agents

Ganetsky, M., et al, Acad Emerg Med Epub ahead of print, May 5, 2017 

BACKGROUND: The rate of intracranial bleeding In ED patients with head injury after a ground-level fall who have been using antiplatelet or anticoagulant agents is unclear, particularly after the introduction and increasing use of the new direct oral anticoagulants.

METHODS: The multinational authors of this prospective, observational cohort study report head CT findings in 939 patients (mean age 78.3) who presented to the ED of an urban Level I trauma center with head injury after a ground-level fall (or from a lesser height) and were taking aspirin, clopidogrel, prasugrel, ticagrelor, warfarin, dabigatran, rivaroxaban or enoxaparin. Of these, 71.1% were receiving antiplatelet treatment, 19.2% anticoagulants, and 9.7% both. The most common agent was aspirin (78%) followed by warfarin (24%). Direct oral anticoagulants were being used by just 3.3%. The primary outcome was traumatic intracranial hemorrhage on initial head CT.

RESULTS: The overall rate of traumatic intracranial hemorrhage was 3.5%: 4.3% in patients taking antiplatelet agents and 1.7% in those taking anticoagulants (p=NS). The rate was 4.6% with aspirin alone (mostly low-dose) and 2.1% with warfarin alone with a mean INR 3.3. No intracranial hemorrhage was detected in patients taking direct oral anticoagulants. Patients with intracranial hemorrhage were significantly more likely to have external signs of head trauma and loss of consciousness. The mortality rate was 0.9% at 7 days and 3.2% at 30 days. The antiplatelet and anticoagulant groups had similar ED disposition and mortality rates. The mortality rate among those with intracranial hemorrhage was 12.1%.

CONCLUSIONS: The rate of intracranial hemorrhage after a ground level fall in patients taking antiplatelet or anticoagulant agents was 3.5%. An unexpected finding was the similar rate with low-dose aspirin and anticoagulants. 26 references (mganetsk@bidmc.harvard.edu for reprints)

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