M. Harris1, A. Ratnasekera1, D. Roberge Bouchard1, J. Getchell1, J. Sciacca1, J. Kuiper1, A. Brackett1, S. Rastogi4, H. Brady3, V. Parthiban5, C. Richard2, C. Jurkovitz2, L. Cardenas1, J. Imran1 2ChristianaCare, Institute For Research On Equity And Community Health (iREACH), Newark, DE, USA 3Lincoln Memorial University DeBusk College of Osteopathic Medicine, Harrogate, TN, USA 4University of Delaware, Newark, DE, USA 5Sidney Kimmel Medical College, Philadelphia, PA, USA 1ChristianaCare, Trauma And Surgical Critical Care, Newark, DE, USA
Introduction: Traumatic brain injury (TBI) is responsible for the utilization of vast healthcare resources. Given the aging population in the United States and the increased use of anticoagulation medication, patients are at higher risk of bleeding and intracranial hemorrhage (ICH) after trauma. There is a paucity of data on the management of anticoagulated TBI patients, especially in those with low risk for progression based on size criteria. We sought to analyze outcomes of low-risk patients on anticoagulation based on whether or not they received reversal agents in the management of their TBI.
Methods: A single center retrospective review of all adult TBI patients on pre-hospital anticoagulation and evidence of ICH on CT imaging was conducted. Patients admitted from January 2016 to December 2022 were stratified into low and high risk for TBI progression based on hemorrhage size using modified Berne-Norwood criteria. Patients were further stratified based on receiving anticoagulation reversal in the form of prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP). Primary outcome was radiographic intracranial hemorrhage expansion (ICHE). Secondary outcomes included neurosurgical intervention, venous thromboembolism (VTE), and mortality.
Results: Overall, 136 low-risk patients on anticoagulation with ICH were identified. Of those, 36 (26.5%) were on Warfarin, 67 (49.3%) on a novel oral anticoagulant, and 33 (24.5%) on an unspecified anticoagulant. Out of 136 patients, 22 (16.2%) received reversal and 114 (83.8%) did not. There were no differences in baseline demographics or comorbidities amongst both groups (p > 0.05). Median GCS on arrival was similar between groups (15 vs 15, p = 0.297). Subdural hematoma (SDH) was the predominant ICH in both groups (72.7% in those reversed vs 79.8% in those not reversed). There was no difference in median size of SDH in those reversed compared to those not reversed (4mm vs 3mm, p = 0.36). Of the 22 who received reversal, 9 (40.9%) had ICHE on repeat imaging compared to 31 (27.2%) of the 114 who did not receive reversal. One patient (4.5%) receiving reversal required craniotomy compared to two patients (1.8%) who did not receive reversal. VTE rates were higher in those who received reversal (9.1% vs 0%). Mortality was higher in patients who were reversed than those who were not (9.1% vs 2.6%, p = 0.166). Reversal was the most predictive factor for ICHE and hospital LOS using lasso regression.
Conclusion: TBI patients on anticoagulation who are low risk for ICH progression based on size using Berne-Norwood criteria carry a considerable risk for ICHE, even after receiving reversal agents. We observed proportionally more ICHE in patients receiving reversal although not statistically distinguishable. Both mortality and incidence of VTE were higher in patients who were reversed. The question remains if the benefits of reversal outweigh the risks in this patient population.