LO47: Incidence of intracranial bleeding in anticoagulated emergency patients with minor head injury: a meta-analysis

Abstract

Introduction: The proportion of Canadians receiving anticoagulation medication is increasing. Falls in the elderly are the most common cause of minor head injury and an increasing proportion of these patients are prescribed anticoagulation. Emergency department (ED) guidelines advise performing a CT head scan for all anticoagulated head injured patients, but the risk of intracranial hemorrhage (ICH) after a minor head injury (patients who have a Glasgow comma score (GSC) of 15) is unclear. We conducted a systematic review and meta-analysis to determine the point incidence of ICH in anticoagulated ED patients presenting with a minor head injury. Methods: We systematically searched Pubmed, EMBASE, Cochrane database, DARE, google scholar and conference abstracts (May 2017). Experts were contacted. Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE) guidelines were followed with two authors reviewing titles, four authors reviewing full text and four authors performing data extraction. We included all prospective studies recruiting consecutive anticoagulated ED patients presenting with a head injury. We obtained additional data from the authors of the included studies on the subset of GCS 15 patients. We performed a meta-analysis to estimate the point incidence of ICH among patients with a GCS score of 15 using a random effects model. Results: A total of five studies (and 4,080 GCS 15, anticoagulated patients) from the Netherlands, Italy, France, USA and UK were included in the analysis. One study contributed 2,871 patients. Direct oral anticoagulants were prescribed in only 60 (1.5%) patients. There was significant heterogeneity between studies with regards to mechanism of injury, CT scanning and follow up method (I2 =93%). The random effects pooled incidence of ICH was 8.9% (95% CI 5.0-13.8%). Conclusion: We found little data to reflect contemporary anticoagulant prescribing practice. Around 9% of warfarinized patients with a minor head injury develop ICH. Future studies should evaluate the safety of selective CT head scanning in this population.