Antithrombotic Use In Patients with Mild Brain Injury May Not Mandate Brain Injury Guidelines (BIG) Elevation

Abstract

Background The Brain Injury Guidelines (BIG) provide an approach to stratify TBI patients into 3 categories of severity (BIG 1 to 3) by variables including anatomic size, location, and the use of antiplatelet agents (APA) and anticoagulants (AC). The BIG classify patients on APA or AC as BIG 3 regardless of injury severity, indicating a therapeutic plan involving hospitalization, neurosurgery consultation, and repeat head CT (RHCT). Current evidence is controversial when comparing hematoma progression rates in TBI patients on APA/AC therapies. We evaluated whether pre-injury antiplatelet or anticoagulant use in TBI patients alone should disqualify them from BIG 1 consideration, and if appropriate reclassification could help conserve hospital resources without compromising patient safety. Methods This retrospective study investigated TBI patients presenting to the ED of an urban Level I trauma center from January 2018 until March 2022. Patients categorized as BIG 3 due to prehospital APA/AC use but otherwise fitting all requirements of a BIG 1 injury classification (“Anatomical BIG 1”) were compared to patients with similar anatomic injuries (“True BIG 1”). Head CT progression rates between these two groups were compared. Results 271 TBI patient records were examined. 27 patients were sorted as true BIG 1, 49 patients as BIG 2, and 195 patients as BIG 3. Thirty five “anatomic BIG 1” patients classified as BIG 3 due to APA/AC status were identified. 19 patients were on APA therapy, 5 were on a DOAC, 3 were on clopidogrel, 3 were on dual APA therapy, 2 were on warfarin, 2 were on dual APA/DOAC therapy, and 1 was on dual APA/AC therapy. All 35 patients showed no progression on RHCT. Conclusion Antithrombotic (AT) use in patients with anatomic BIG 1 brain injuries does not appear to increase risk of progression. Pre-hospital AT use consequently does not appear to warrant escalation of care to BIG 3 in patients with such injuries. This could increase patient savings on hospitalization costs as well as reduce exposure to radiation as current practice guidelines indicate that an RHCT not necessary for BIG 1 brain injuries.