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. 2023 Jan 27:10:1117777.
doi: 10.3389/fmed.2023.1117777. eCollection 2023.

Cranial CT is a mandatory tool to exclude asymptomatic cerebral hemorrhage in elderly patients on anticoagulation

Cora R Schindler  1 , Alicia Best  1 , Mathias Woschek  1 , René D Verboket  1 , Ingo Marzi  1 , Katrin Eichler  2 , Philipp Störmann  1
Affiliations

Cranial CT is a mandatory tool to exclude asymptomatic cerebral hemorrhage in elderly patients on anticoagulation

Cora R Schindler et al. Front Med (Lausanne). .

Abstract

Background: Traumatic brain injury (TBI) after falls causes death and disability with immense socioeconomic impact through medical and rehabilitation costs in geriatric patients. Diagnosing TBI can be challenging due to the absence of initial clinical symptoms. Misdiagnosis is particularly dangerous in patients on permanent anticoagulation because minimal trauma might result in severe intracranial hemorrhage. The aim of this study is to evaluate the diagnostic necessity of cranial computed tomography (cCT) to rule out intracranial hemorrhage, particularly in the absence of neurologic symptoms in elderly patients on permanent anticoagulation in their premedication.

Patients and methods: Retrospective cohort analysis of elderly trauma patients (≥ 65 years) admitted to the emergency department (ED) of the level-1-trauma center of the University Hospital Frankfurt from 01/2017 to 12/2019. The study included patients who suffered a ground-level fall with suspected TBI and subsequently underwent CT because of preexisting anticoagulation.

Results: A total of 227 patients met the inclusion criteria. In 17 of these patients, cCT showed intracranial hemorrhage, of which 14 were subdural hematomas (SDH). In 8 of the patients with bleeding showed no clinical symptoms, representing 5% (n = 160) of all symptom-free patients. Men and women were equally to suffer a post-traumatic hemorrhage. Patients with intracranial bleeding were hospitalized for 14.5 (±10.4) days. Acetylsalicylic acid (ASA) was the most prescribed anticoagulant in both patient cohorts-with or without intracerebral bleeding (70.6 vs. 77.1%, p = 0.539). Similarly, patients taking new oral anticoagulant (NOAC) (p = 0.748), coumarins, or other platelet inhibitors (p > 0.1) did not show an increased bleeding incidence.

Conclusion: Acetylsalicylic acid and NOAC use are not associated with increased bleeding risk in geriatric trauma patients (≥ 65 years) after fall-related TBI. Even in asymptomatic elderly patients on anticoagulation, intracranial hemorrhage occurs in a relevant proportion after minor trauma to the head. Therefore, cCT is an obligatory tool to rule out cerebral hemorrhage in elderly patients under anticoagulation.

Keywords: TBI; anticoagulation; cerebral hemorrhage; computertomografie; elderly; geriatric TBI.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Anticoagulants taken in patients with and without cerebral hemorrhage after TBI (ASA, acetylsalicylic acid; LMWH, low-molecular-weight heparin; NOAC, novel oral anticoagulants; PAI, platelet aggregation inhibitor). *p ≤ 0.05, **p ≤ 0.01, and ***p < 0.001.
FIGURE 2
FIGURE 2
Distribution of different bleeding entities of geriatric patients (≥ 65 years) after TBI. In some patients, different bleeding entities were present simultaneously: SDH, subdural hematoma (n = 14); SAH, subarachnoid hemorrhage (n = 3); ICH, intracerebral hemorrhage (n = 3).
FIGURE 3
FIGURE 3
Exemplary cranial CT images of a 73-year-old male patient admitted to the emergency department of the University Hospital Frankfurt after a ground-level fall under ASA premedication. The CT scan shows the simultaneous presence of a subdural hematoma (A) and an intracerebral hemorrhage (B). ©Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany.
FIGURE 4
FIGURE 4
Major and minor symptoms in patients with and without cerebral hemorrhage after TBI (LOC, loss of consciousness).
See this image and copyright information in PMC

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