Abstract
IntroductionEvaluation recommendations for patients on anticoagulant and antiplatelet (ACAP) therapy that present after mild traumatic brain injury (TBI) are controversial. At our institution, an initial noncontrast head computed tomography (HCT) is performed, with a subsequent HCT performed six hours later to exclude delayed intracranial hemorrhage (ICH). This study was performed to evaluate the yield and advisability of this approach.MethodsWe performed a retrospective review of subjects undergoing evaluation for ICH after mild TBI in patients on ACAP therapy between January of 2012 and April of 2013. We assessed for the frequency of ICH on both the initial noncontrast HCT and on the routine six-hour follow-up HCT. Additionally, chart review was performed to evaluate the clinical implications of ICH, when present, and to interrogate whether pertinent clinical and laboratory data may predict the presence of ICH prior to imaging. We used multivariate generalized linear models to assess whether presenting Glasgow Coma Score (GCS), loss of consciousness (LOC), neurological or physical examination findings, international normalized ratio, prothrombin time, partial thromboplastin time, platelet count, or specific ACAP regimen predicted ICH.Results144 patients satisfied inclusion criteria. Ten patients demonstrated initial HCT positive for ICH, with only one demonstrating delayed ICH on the six-hour follow-up HCT. This patient was discharged without any intervention required or functional impairment. Presenting GCS deviation (p<0.001), LOC (p=0.04), neurological examination findings (p<0.001), clopidogrel (p=0.003), aspirin (p=0.03) or combination regimen (p=0.004) use were more commonly seen in patients with ICH.ConclusionRoutine six-hour follow-up HCT is likely not indicated in patients on ACAP therapy, as our study suggests clinically significant delayed ICH does not occur. Additionally, presenting GCS deviation, LOC, neurological examination findings, clopidogrel, aspirin or combination regimen use may predict ICH, and, in the absence of these findings, HCT may potentially be forgone altogether.
Highlights
Evaluation recommendations for patients on anticoagulant and antiplatelet (ACAP) therapy that present after mild traumatic brain injury (TBI) are controversial
Routine six-hour follow-up head computed tomography (HCT) is likely not indicated in patients on Anticoagulation or antiplatelet (ACAP) therapy, as our study suggests clinically significant delayed intracranial hemorrhage (ICH) does not occur
Review of the existing literature regarding its appropriate use in patients on ACAP therapy, in cases of mild TBI, yields conflicting results with some authors concluding that imaging may not always be indicated,[6,7] others contending that at least an initial HCT is prudent in patients on ACAP due to increased risk of injury without reliable pretest risk factors,[8,9,10] and still others advocating serial imaging after an initial negative HCT to evaluate for delayed ICH.[11]
Summary
Evaluation recommendations for patients on anticoagulant and antiplatelet (ACAP) therapy that present after mild traumatic brain injury (TBI) are controversial. Patients on ACAP agents who present to the ED after mild TBI are routinely evaluated with an initial non-contrast HCT and a six-hour follow-up HCT if the first is negative to exclude delayed ICH prior to discharge. While this method is certainly reasonable given the lack of consensus data regarding this subject, the advisability of this or similar approaches has been called into question.[12,13] In an era of stringent healthcare resource utilization measures and radiation safety concerns, expensive algorithms that rely heavily on imaging must be thoroughly evaluated.
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