Patients on DOAC have minimal risk of delayed ICH after low energy blunt head trauma

USA: For individuals on direct oral anticoagulants (DOACs), the risk of delayed intracranial hemorrhage (ICH) following low-intensity blunt head trauma is minimal, and the chance of a clinically significant bleed is much lower, says an article published in the Journal of the American College of Surgeons.

Delayed ICH following a negative first head cat scan (CT) is a known consequence of physical trauma, although the risk of this syndrome is unclear. There is a lack of consensus about the necessity for further observation or routine repeat head CT in patients on direct oral anticoagulants due to the possible increased risk and difficulty to assess the degree of anticoagulation. As a result, Thaddeus J. Puzio and colleagues anticipated that patients using DOACs would have a low incidence of delayed ICH following blunt head trauma.

A medical librarian (TH) did an electronic literature search of Embase (Elsevier), MEDLINE (Ovid), and Cochrane Library in June 2020 using a mix of keywords and subject headings. Databases were searched from their establishment till June 2020. The included studies reported on the outcomes of trauma patients over the age of 18 who were undertaking anticoagulants and were monitored after an initial normal head CT. A random-effects model was used in a meta-analysis. The Newcastle-Ottawa Scale (NOS) was used in meta-analyses to assess the quality of nonrandomized research.

The key findings of this study are as follow:

1. The computerized search yielded 5719 publications, of which 72 received a complete review and 12 fulfilled final inclusion/exclusion criteria after duplicates were removed.

2. Four thousand eight hundred ninety-one (92%) of the 5289 patients (92%) sustained a ground-level fall.

3. Four studies reported regular repeat CT scans on all patients, while the remaining studies only reported symptoms-related repeat CT scans.

4. In all, 5289 individuals were investigated, with 1263 (23.9%) taking a DOAC. Sixty-nine patients, 25 on DOAC and 44 on warfarin, experienced delayed cerebral bleeding.

5. The pooled weighted proportion of delayed ICH on DOAC was 2.43%, while warfarin had a rate of 2.31%.

6. 86% of patients (59/69) who experienced delayed ICH had no clinical implications, but 0.16% (2/1263) of those on DOAC and 0.48% (8/1788) of those on warfarin died as a result of problems caused by delayed ICH.

7. Overall, the crude risk of mortality from delayed ICH while using DOAC or Warfarin was 0.36% (11/3051).

In conclusion, routinely watching or systematically repeating head CT in patients on DOACs following low energy blunt head trauma with initially negative head CT may not be needed.

Reference:

Puzio TJ, Murphy PB, Kregel HR, et al. Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis. J Am Coll Surg. 2021;232(6):1007-1016.e5. doi:10.1016/j.jamcollsurg.2021.02.016