Delayed Intracranial Hemorrhage in Anticoagulated Geriatric Patients After Ground Level Falls

• Published in: The Journal of emergency medicine 2019-12, Vol.57 (6), p.812-816
• Main Authors: Cocca, Alexandra T., Privette, Alicia, Leon, Stuart M., Crookes, Bruce A., Hall, Gregory, Lena, Jonathan, Eriksson, Evert A.
• Format: Article
• Language: English
• Subjects: apixaban; dabigatran; geriatric; intracranial hemorrhage; NOAC; rivaroxaban; traumatic brain injury; warfarin
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2019.09.011

The reported risk of delayed intracranial hemorrhage (ICH) in a trauma patient on warfarin is estimated to be between 0.6% and 6%. The risk of delayed ICH in trauma patients taking novel oral anticoagulants (NOACs) is not well-defined. We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs. A retrospective review of our trauma registry was performed on geriatric patients (age older than 64 years) who were initially evaluated at our level I trauma center, had fall from standing height or less, and were anticoagulated (warfarin or NOACs), from April 2017 to March 2018. Seventy-seven patients met inclusion criteria. The mean age was 80 ± 7.7 years and 46% of patients were male. The admission head computed tomography scan was positive in 20.8% of patients. Positive scans were more common in patients on warfarin vs. NOACs (30% vs. 14%; p = 0.074) and had a significantly higher Injury Severity Score (median [interquartile range]: 9 [3–15] vs. 5 [1–9]; p = 0.030) and Abbreviated Injury Scale–Head score (median [interquartile range]: 1 [0–3] vs. 1 [0–2]; p = 0.035). The agreement between loss of consciousness (LOC) and ICH was 72% (κ = –0.064; p = 0.263). Fifty-one percent of patients had a repeat head CT. New ICH was diagnosed in 9.6% of patients. All of these patients were on NOACs. A fall from standing or less in anticoagulated geriatric patients is a significant mechanism of injury resulting in ICH. The absence of LOC does not eliminate the possibility of ICH. There is a significant risk of delayed ICH for patients on NOACs and repeat evaluations should be performed. A prospective multicenter evaluation of this finding is warranted.