The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old

Oliver Prexl,Marc Maegele,Martin Bruckbauer,Oliver Grottke,Herbert Schöchl,Martin Ponschab,Wolfgang Voelckel

doi:10.1186/s13049-018-0487-0

Abstract

BackgroundTraumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. There is a paucity of data about the role of direct oral anticoagulants (DOACs) among TBI patients.MethodsIn this retrospective study, we investigated all TBI patients ≥60-years-old who were admitted to the intensive care unit (ICU) from January 2014 until May 2017. Patients were grouped into those receiving vitamin K antagonists (VKA), platelet inhibitors (PI), DOACs and no antithrombotic therapy (no-ATT).ResultsOne-hundred-eighty-six, predominantly male (52.7%) TBI patients with a median age of 79 years (range: 70–85 years) were enrolled in the study. Glasgow Coma Scale and S-100β were not different among the groups. Patients on VKA and DOACs had a higher Charlson Comorbidity Index compared to the PI group and no-ATT group (p = 0.0021). The VKA group received reversal agents significantly more often than the other groups (p < 0.0001). Haematoma progression in the follow-up cranial computed tomography (CCT) was lowest in the DOAC group. The number of CCT and surgical interventions were low with no differences between the groups. No relevant differences in ICU and hospital length of stay were observed. Mortality in the VKA group was significantly higher compared to DOAC, PI and no-ATT group (p = 0.047).DiscussionData from huge registry studies displayed higher efficacy and lower fatal bleeding rates for DOACs compared to VKAs. The current study revealed comparable results. Despite the fact that TBI patients on VKAs received reversal agents more often than patients on DOACs (84.4% vs. 24.2%, p < 0.001), mortality rate was significantly higher in the VKA group (p = 0.047).ConclusionIn patients ≥60 years suffering from TBI, anticoagulation with DOACs appears to be safer than with VKA. Anti-thrombotic therapy with VKA resulted in a worse outcome compared to DOACs and PI. Further studies are warranted to confirm this finding.

Highlights

Traumatic brain injury (TBI) is the leading cause of death among trauma patients
In patients ≥60 years suffering from TBI, anticoagulation with Direct oral anticoagulant (DOAC) appears to be safer than with vitamin K antagonists (VKA)
Forty-one patients had an ongoing medication with platelet inhibitors (PI), patients were anticoagulated with VKA and the remaining with DOACs

Summary

Introduction

Traumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. Severe traumatic brain injury (TBI) remains the leading cause of death among trauma patients [1]. Multiple studies have identified a peak in TBI incidence among the oldest age groups [2]. Compared to young and previously healthy TBI victims, elderly patients showed worse outcome. This is, in part, linked to age-related comorbidities. Multiple studies have shown that patients under ATT carry an increased risk for intracranial haemorrhage (ICH) or haematoma progression following severe TBI [3,4,5]

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