The use of routine observation and serial cranial computed tomography for the identification of delayed traumatic intracranial hemorrhage (TIH) in older adults with blunt head trauma taking an anticoagulant or antiplatelet therapy is not necessary, considering the incidence of delayed TIH is low in these patients, according to prospective findings from an observational, multicenter study published in JAMA Surgery.
In this study, patients with blunt head trauma ≥55 years who were admitted to the hospital through emergency medical services (n=859) were included. Overall, investigators evaluated patients who were admitted to 1 of 11 hospitals in the northern California region. At time of study enrollment, approximately 39.9% (n=343) of patients were receiving anticoagulant or antiplatelet therapy. The incidence of delayed TIH <14 days after injury comprised the primary outcome.
A total of 3 patients (0.3%; 95% CI, 0.1%-1.0%) had a TIH at evaluation. One of these patients was receiving warfarin sodium monotherapy (1.3%; 95% CI, 0.0%-7.2%), and 2 were not receiving any anticoagulant or antiplatelet therapy (0.4%; 95% CI, 0.1%-1.4%). Patients taking aspirin, other antiplatelet therapies, direct-acting oral anticoagulants, or concomitant medications did not have a delayed TIH. Up to 4.5% (n=39) of patients were unavailable at time of telephone follow-up, whereas 30 patients (3.5%; 95% CI, 2.3%-4.9%) had died. None of the patients who had died had repeat hospitalization or emergency department visits caused by delayed TIH.
The investigators suggest that 39 lost to follow up and 30 patients who had died may have had an undiagnosed delayed TIH. Additionally, only patients transported by means of emergency medical services were enrolled, suggesting that these findings are limited to those with more severe blunt head injury vs those who self-present to the emergency department.
Findings from this study indicate the “importance of clinical judgment regarding the severity of trauma, additional injuries, and ability to monitor the patient for deterioration when making decisions about admission for older patients after blunt head trauma.”
Chenoweth JA, Gaona SD, Faul M, Holmes JF, Nishijima DK; for the Sacramento County Prehospital Research Consortium. Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma [published online February 14, 2018]. JAMA Surg. doi:10.1001/jamasurg.2017.6159