Delayed Intracranial Hemorrhage in Anticoagulated Geriatric Patients After Ground Level Falls

Abstract

Background: 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.

Objective: We hypothesized that there was a significant number of delayed presentations of ICH in patients on NOACs.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: NOAC; apixaban; dabigatran; geriatric; intracranial hemorrhage; rivaroxaban; traumatic brain injury; warfarin.