Outcome of Nonoperative Management of Selected Cases of Acute Traumatic Intracranial Hematomas in a Rural Neurosurgical Service of a Developing Country.

OBJECTIVE: In resource-limited settings, the standard of care prescribed in developed countries for either operative or nonoperative management of traumatic intracranial hematomas (TICHs) frequently has to be adapted to the economic and infrastructural realities. This study aims to present the outcome of selected cases of TICHs managed nonoperatively without routine intensive care unit admission, repeated cranial computed tomography (CT) scan or intracranial pressure monitoring at a rural neurosurgical service in a developing country. METHODS: This was a retrospective analysis of a cohort of our patients with cranial CT-confirmed TICHs selected for nonoperative treatment from our prospective head injury (HI) register over a 42-month period. RESULTS: There were 67 patients (51 males) in this study with a mean age of 38.6 (standard deviation, 17.6) years, having mild HI in >half, (55.2%, 37/67) and anisocoria in 22.4% (15/67). Road traffic accident was the most common (50/67, 74.7%) trauma etiology. Isolated acute-subdural hematoma, intracerebral hemorrhage, and epidural hematoma occurred in 29.9%, 25.4%, and 22.4% of the patients respectively. Only 2 of 8 patients in whom intensive care unit admission was deemed necessary could afford admission. Repeat cranial CT scan was requested in 8 patients (8/67, 11.9%); only 5 of these could afford the investigation. The outcome of care was good in 82.1% patients (55/67). Increasing severity of the HI (P < 0.01) and presence of pupillary abnormality (P = 0.03) were significant predictors of poor outcome. CONCLUSIONS: In a Nigerian rural neurosurgery practice, nonoperative management of a well-selected cohort of TICHs was attended by acceptable level of favorable outcome.

Antiplatelet therapy contributes to a higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy in ground-level falls: a single-center retrospective study.

BACKGROUND: Traumatic brain injury (TBI) is a common injury and constitutes up to 3% of emergency department (ED) visits. Current studies show that TBI is most commonly inflicted in older patients after ground-level falls. These patients often take medications affecting coagulation such as anticoagulants or antiplatelet drugs. Guidelines for ED TBI-management assume that anticoagulation therapy (ACT) confers a higher risk of traumatic intracranial hemorrhage (TICH) than antiplatelet therapy (APT). However, recent studies have challenged this. This study aimed to evaluate if oral anticoagulation and platelet inhibitors affected rate of TICH in head-trauma patients with ground-level falls. METHODS: This was a retrospective review of medical records during January 1, 2017 to December 31, 2017 and January 1 2020 to December 31, 2020 of all patients seeking ED care because of head-trauma. Patients ≥ 18 years with ground-level falls were included. RESULTS: The study included 1938 head-trauma patients with ground-level falls. Median age of patients with TICH was 81 years. The RR for TICH in APT-patients compared to patients without medication affecting coagulation was 1.72 (p = 0.01) (95% Confidence Interval (CI) 1.13-2.60) and 1.08 (p = 0.73), (95% CI 0.70-1.67) in ACT-patients. APT was independently associated with TICH in regression analysis (OR 1.59 (95% CI 1.02-2.49), p = 0.041). CONCLUSION: This study adds to the growing evidence that APT-patients with ground-level falls might have as high or higher risk of TICH than ACT-patients. This is not addressed in the current guidelines which may need to be updated. We therefore recommend broad prospective studies.

Routine platelet transfusion in patients with traumatic intracranial hemorrhage taking antiplatelet medication: Is it warranted?

BACKGROUND: After a traumatic intracranial hemorrhage (tICH), patients often receive a platelet transfusion to reverse the effects of antiplatelet medication and to reduce neurologic complications. As platelet transfusions have their own risks, this study evaluated their effects on tICH progression, need for operations and mortality. METHODS: In this retrospective study, we identified patients admitted to a level 1 trauma centre with a tICH from 2011 to 2015 who were taking acetylsalicylic acid (ASA) or clopidogrel, or both. We categorized patients into 2 groups: platelet transfusion recipients and nonrecipients. We collected data on demographic characteristics, changes in brain computed tomography findings, neurosurgical interventions, in-hospital death and intensive care unit (ICU) length of stay (LOS). We used multivariable logistic regression to compare outcomes between the 2 groups. RESULTS: We identified 224 patients with tICH, 156 (69.6%) in the platelet transfusion group and 68 (30.4%) in the no transfusion group. There were no between-group differences in progression of bleeds or rates of neurosurgical interventions. In the transfusion recipients, there was a trend toward increased ICU LOS (adjusted odds ratio [OR] 1.59, 95% confidence interval [CI] 0.74-3.40) and in-hospital death (adjusted OR 3.23, 95% CI 0.48-21.74). CONCLUSION: There were no differences in outcomes between patients who received platelet transfusions and those who did not; however, the results suggest a worse clinical course, as indicated by greater ICU LOS and mortality, in the transfusion recipients. Routine platelet transfusion may not be warranted in patients taking ASA or clopidogrel who experience a tICH, as it may increase ICU LOS and mortality risk.

Rapid detection of platelet inhibition and dysfunction in traumatic brain injury: A prospective observational study.

BACKGROUND: Rapid platelet function testing is frequently used to determine platelet function in patients with traumatic intracranial hemorrhage (tICH). Accuracy and clinical significance of decreased platelet response detected by these tests is not well understood. We sought to determine whether VerifyNow and whole blood aggregometry (WBA) can detect poor platelet response and to elucidate its clinical significance for tICH patients. METHODS: We prospectively enrolled patients with isolated tICH between 2018 and 2020. Demographics, medical history, injury characteristics, and patient outcomes were recorded. Platelet function was determined by VerifyNow and WBA testing at the time of arrival to the trauma bay and 6 hours later. RESULTS: A total of 221 patients were enrolled, including 111 patients on no antiplatelet medication, 78 on aspirin, 6 on clopidogrel, and 26 on aspirin and clopidogrel. In the trauma bay, 29.7% and 67.7% of patients on no antiplatelet medication had poor platelet response on VerifyNow and WBA, respectively. Among patients on aspirin, 72.2% and 82.2% had platelet dysfunction on VerifyNow and WBA. Among patients on clopidogrel, 67.9% and 88.9% had platelet dysfunction on VerifyNow and WBA. Patients with nonresponsive platelets had similar in-hospital mortality (3 [3.0%] vs. 6 [6.3%], p = 0.324), tICH progression (26 [27.1%] vs. 24 [26.1%], p = 0.877), intensive care unit admission rates (34 [34.3%] vs. 38 [40.0%), p = 0.415), and length of stay (3 [interquartile range, 2-8] vs. 3.2 [interquartile range, 2-7], p = 0.818) to those with responsive platelets. Platelet transfusion did not improve platelet response or patient outcomes. CONCLUSION: Rapid platelet function testing detects a highly prevalent poor platelet response among patients with tICH, irrespective of antiplatelet medication use. VerifyNow correlated fairly with whole blood aggregometry among patients with tICH and platelet responsiveness detectable by these tests did not correlate with clinical outcomes. In addition, our results suggest that platelet transfusion may not improve clinical outcomes in patients with tICH. LEVEL OF EVIDENCE: Diagnostic tests, level II.

Platelet dysfunction in patients with traumatic intracranial hemorrhage: Do desmopressin and platelet therapy help or harm?

BACKGROUND: Pre-injury anti-platelet use has been associated with increased risk of progression of traumatic intracranial hemorrhage (TICH) and worse outcomes. VerifyNow® assays assess platelet inhibition due to aspirin/clopidogrel. This study assesses the outcomes of patients with TICH and platelet dysfunction treated with desmopressin and/or platelets. METHODS: We performed a retrospective chart review of patients with mild TICH at a level 1 trauma center 1/1/2013-6/1/2016. Patients with documented platelet dysfunction who received desmopressin and/or platelets were compared to those who were untreated. Primary outcomes were progression of TICH and neurologic outcomes at discharge. RESULTS: Of 565 patients with a mild TICH, 200 patients had evidence of platelet dysfunction (a positive VerifyNow® assay). Patients had similar baseline demographics, injury characteristics, and rate of TICH progression; but patients who received desmopressin and/or platelets had worse Glasgow Outcomes Score at discharge. CONCLUSION: Treatment of patients with mild TICH and platelet dysfunction with desmopressin and/or platelets did not affect TICH progression but correlated with worse neurologic status at discharge.

Coagulopathy and Progression of Intracranial Hemorrhage in Traumatic Brain Injury: Mechanisms, Impact, and Therapeutic Considerations.

BACKGROUND: Traumatic brain injury (TBI) remains one of the most challenging health and socioeconomic problems of our times. Clinical courses may be complicated by hemostatic abnormalities either pre-existing or developing with TBI. OBJECTIVE: To review frequencies, patterns, mechanisms, novel approaches to diagnostics, treatment, and outcomes of hemorrhagic progression and coagulopathy after TBI. METHODS: Selective review of the literature in the databases Medline (PubMed) and Cochrane Reviews using different combinations of the relevant search terms was conducted. RESULTS: Of the patients, 20% with isolated TBI display laboratory coagulopathy upon hospital admission with profound effect on morbidity and mortality. Preinjury use of antithrombotic agents may be associated with higher rates of hemorrhagic progression and delayed traumatic intracranial hemorrhage. Further testing may display various changes affecting platelet function/numbers, pro- and/or anticoagulant factors, and fibrinolysis as well as interactions between brain tissues, vascular endothelium, mechanisms of inflammation, and blood flow dynamics. The nature of hemostatic disruptions after TBI remains elusive but current evidence suggests the presence of both a hyper- and hypocoagulable state with possible overlap and lack of distinction between phases and states. More "global" hemostatic assays, eg, viscoelastic and thrombin generation tests, may provide more detailed and timely information on the overall hemostatic potential thereby allowing early "goal-directed" therapies. CONCLUSION: Whether timely and targeted management of hemostatic abnormalities after TBI can protect against secondary brain injury and thereby improve outcomes remains elusive. Innovative technologies for diagnostics and monitoring offer windows of opportunities for precision medicine approaches to managing TBI.

ABO blood groups do not predict progression of traumatic intracranial hemorrhage.

ABO blood groups are associated with genetically predisposed variations in von Willebrand factor (VWF) resulting in higher risks of thrombotic events in non-O blood types and bleeding complications in blood type O. The role of ABO blood groups in progression of traumatic intracranial hemorrhage (TICH) is unknown. Given statistically lower VWF levels in blood type O in the general population, we hypothesized that blood type O patients have a higher risk of such progression. A retrospective review of adult trauma patients with isolated TICH admitted to a Level 1 trauma center over eight years was conducted. Patients were categorized with blood type O and non-O (types A, B, AB) delineation. The primary outcome was radiological progression of TICH during the first 24 h. Secondary outcomes included surgical intervention after follow-up computed tomography (CT), complications, days on mechanical ventilation (DMV), intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Of 949 patients, 432 (45.5%) had blood type O. When comparing O and non-O groups, no significant differences were found in gender, age, race, admission vital signs, Glasgow Coma Scale, coagulation profile, TICH type, or Injury Severity Score. No difference in TICH progression was found between O and non-O groups: 73 (17%) vs 80 (15%), respectively, p = 0.55. Blood type O mortality was 12 (3% vs. 23 (4%), p = 0.174). Rate of TICH surgical intervention after follow-up CT, DMV, complications, and ICU and hospital LOS did not differ. No association between ABO blood types and radiological progression of TICH was identified.

Platelet Reactivity Testing for Aspirin Patients Who Sustain Traumatic Intracranial Hemorrhage.

BACKGROUND: Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. METHODS: This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. RESULTS: 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). CONCLUSIONS: Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.

Assessing the efficacy of mild traumatic brain injury management.

OBJECTIVE: Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI. METHODS: Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included. RESULTS: Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion. CONCLUSION: Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Choosing the Best Approach to Warfarin Reversal After Traumatic Intracranial Hemorrhage.

BACKGROUND: Patients on warfarin with traumatic intracranial hemorrhage often have the warfarin effects pharmacologically reversed. We compared outcomes among patients who received 4-factor prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or no reversal to assess the real-world impact of PCC on elderly patients with traumatic intracranial hemorrhage (ICH). MATERIALS AND METHODS: This was a retrospective analysis of 150 patients on preinjury warfarin. Data were manually abstracted from the electronic medical record of an academic level 1 trauma center for patients admitted between January 2013 and December 2018. Outcomes were ICH progression on follow-up computed tomography scan, mortality, need for surgical intervention, and trends in the use of reversal agents. RESULTS: Of 150 patients eligible for analysis, 41 received FFP, 60 PCC, and 49 were not reversed. On multivariable analysis, patients not reversed [OR 0.25 95% CI (0.31-0.85)] and women [OR 0.38 95% CI (0.17-0.88)] were less likely to experience progression of their initial bleed on follow-up computed tomography while subdural hemorrhage increased the risk [OR 3.69 95% CI (1.27-10.73)]. There was no difference between groups in terms of mortality or need for surgery. Over time use of reversal with PCC increased while use of FFP and not reversing warfarin declined (P < 0.001). CONCLUSIONS: Male gender and using a reversal agent were associated with progression of ICH. Choice of reversal did not impact the need for surgery, hospital length of stay, or mortality. Some ICH patients may not require warfarin reversal and may bias studies, especially retrospective studies of warfarin reversal.

Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents.

BACKGROUND: With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. METHODS: We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. RESULTS: A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. CONCLUSIONS: The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. LEVEL OF EVIDENCE: Level III prognostic.

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14-15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers.

We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14-15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In "screened" patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the "unscreened" group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38). In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14-15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Preinjury Antiplatelet Use Does Not Increase the Risk of Progression of Small Intracranial Hemorrhage.

BACKGROUND: The modified brain injury guidelines (mBIG) provide an algorithm for surgeons to manage some mild traumatic brain injury (TBI) with intracranial hemorrhage (ICH) without neurosurgical consultation or repeat imaging. Currently, antiplatelet use among patients with any ICH classifies a patient at the highest level, mBIG 3. This study assesses the risk of clinical progression among patients taking antiplatelet medications with mild TBI with ICH. METHODS: A retrospective analysis of patients with traumatic ICH over a 5-year period was conducted. Demographics, injury severity, and outcome data were collected for each patient. Patients taking antiplatelet agents were reclassified as if they were not taking these medications. Patients who would have met criteria for a lower classification (mBIG 1 or 2) without antiplatelet agents were designated mBIG 3 Antiplatelet and compared with all other mBIG 1 and 2 patients. RESULTS: 736 patients met the inclusion criteria. 158 patients were taking antiplatelet medications and 53 were reclassified as mBIG 3 Antiplatelet. When comparing mBIG 3 Antiplatelet to the 226 patients originally classified as mBIG 1 and 2, mBIG 3 Antiplatelet patients were more likely to undergo repeat head computed tomography (98.1% vs 76.6%; P < .001) and neurosurgical consultation (94.2% vs 76.5%; P < .001) but had no significant differences in outcomes. No mBIG 3 Antiplatelet patients had a worsening examination or needed operative intervention. DISCUSSION: This data suggests that antiplatelet medication use should not automatically classify a patient as mBIG 3. Adoption of this strategy would better utilize resources and avoid unnecessary costs without sacrificing care.

A systematic review and meta-analysis of traumatic intracranial hemorrhage in patients taking prehospital antiplatelet therapy: Is there a role for platelet transfusions?

BACKGROUND: Platelet transfusion has been utilized to reverse platelet dysfunction in patients on preinjury antiplatelets who have sustained a traumatic intracranial hemorrhage (tICH); however, there is little evidence to substantiate this practice. The objective of this study was to perform a systematic review on the impact of platelet transfusion on survival, hemorrhage progression and need for neurosurgical intervention in patients with tICH on prehospital antiplatelet medication. METHODS: Controlled, observational and randomized, prospective and retrospective studies describing tICH, preinjury antiplatelet use, and platelet transfusion reported in PubMed, Embase, Cochrane Reviews, Cochrane Trials and Cochrane DARE databases between January 1987 and March 2019 were included. Investigations of concomitant anticoagulant use were excluded. Risk of bias was assessed using the Newcastle-Ottawa scale. We calculated pooled estimates of relative effect of platelet transfusion on the risk of death, hemorrhage progression and need for neurosurgical intervention using the methods of Dersimonian-Laird random-effects meta-analysis. Sensitivity analysis established whether study size contributed to heterogeneity. Subgroup analyses determined whether antiplatelet type, additional blood products/reversal agents, or platelet function assays impacted effect size using meta-regression. RESULTS: Twelve of 18,609 screened references were applicable to our questions and were qualitatively and quantitatively analyzed. We found no association between platelet transfusion and the risk of death in patients with tICH taking prehospital antiplatelets (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.76-2.18; p = 0.346; I = 32.5%). There was no significant reduction in hemorrhage progression (OR, 0.88; 95% CI, 0.34-2.28; p = 0.788; I = 78.1%). There was no significant reduction in the need for neurosurgical intervention (OR, 1.00; 95% CI, 0.53-1.90, p = 0.996; I = 59.1%; p = 0.032). CONCLUSION: Current evidence does not support the use of platelet transfusion in patients with tICH on prehospital antiplatelets, highlighting the need for a prospective evaluation of this practice. LEVEL OF EVIDENCE: Systematic Reviews and Meta-Analyses, Level III.

Comparison of Traumatic Intracranial Hemorrhage Expansion and Outcomes Among Patients on Direct Oral Anticoagulants Versus Vitamin k Antagonists.

BACKGROUND: With increasing use of direct oral anticoagulants (DOACs) and availability of new reversal agents, the risk of traumatic intracranial hemorrhage (tICH) requires better understanding. We compared hemorrhage expansion rates, mortality, and morbidity following tICH in patients treated with vitamin k antagonists (VKA: warfarin) and DOACs (apixaban, rivaroxaban, dabigatran). METHODS: Retrospective chart review of patients from 2010 to 2017 was performed to identify patients with imaging diagnosis of acute traumatic intraparenchymal, subdural, subarachnoid, and epidural hemorrhage with preadmission use of DOACs or VKAs. We identified 39 patients on DOACs and 97 patients on VKAs. Demographic information, comorbidities, hemorrhage size, and expansion over time, as well as discharge disposition and Glasgow Outcome Scale (GOS) were collected. Primary outcome was development of new or enlargement of tICH within the first 48 h of initial CT imaging. RESULTS: Of 136 patients with mean (SD) age 78.7 (13.2) years, most common tICH subtype was subdural hematoma (N = 102/136; 75%), and most common mechanism was a fall (N = 130/136; 95.6%). Majority of patients in the DOAC group did not receive reversal agents (66.7%). Hemorrhage expansion or new hemorrhage occurred in 11.1% in DOAC group vs. 14.6% in VKA group (p = 0.77) at a median of 8 and 11 h from initial ED admission, respectively (p = 0.82). Patients in the DOAC group compared to VKA group had higher median discharge GOS (4 vs. 3 respectively, p = 0.03), higher percentage of patients with good outcome (GOS 4-5, 66.7% vs. 40.2% respectively, p = 0.005), and higher rate of discharge to home or rehabilitation (p = 0.04). CONCLUSIONS: We report anticoagulation-associated tICH outcomes predominantly due to fall-related subdural hematomas. Patients on DOACs had lower tICH expansion rates although not statistically significantly different from VKA-treated patients. DOAC-treated patients had favorable outcomes versus VKA group following tICH despite low use of reversal strategies. DOAC use may be a safer alternative to VKA in patients at risk of traumatic brain hemorrhage.

The Association of Trauma Center Transport and Long-term Functional Outcomes in Head-injured Older Adults Transported by Emergency Medical Services.

OBJECTIVE: It is unclear whether trauma center care is associated with improved outcomes in older adults with traumatic brain injury (TBI) compared to management at nontrauma centers. Our primary objectives were to describe the long-term outcomes of older adults with TBI and to evaluate the association of trauma center transport with long-term functional outcome. METHODS: This was a prospective, observational study at five emergency medical services (EMS) agencies and 11 hospitals representing all 9-1-1 transfers within a county. Older adults (≥55 years) with TBI (defined as closed head injury associated with loss of consciousness and/or amnesia, abnormal Glasgow Coma Scale [GCS] score, or traumatic intracranial hemorrhage) and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and emergency department (ED) and hospital data were abstracted. Functional outcomes were measured using the Extended Glasgow Outcome Scale (GOS-E) at 3- and 6-month intervals by telephone follow-up. Reasons for disabilities were coded as due to head injury, due to illness or injury to other part of body, or due to a mixture of both. To evaluate the association of trauma center transport and functional outcomes, we conducted multivariate ordinal logistic regression analyses on multiple imputed data for 1) all patients with TBI and 2) patients with traumatic intracranial hemorrhage. RESULTS: We enrolled 350 patients with TBI; the median (Q1, Q3) age was 70 (61, 84) years, 187 (53%) were male, and 91 patients (26%) had traumatic intracranial hemorrhage on initial ED cranial computed tomography (CT) imaging. A total of 257 patients (73%) were transported by EMS to a Level I or II trauma center. Sixty-nine patients (20%) did not complete follow-up at 3 or 6 months. Of the patients with follow-up, 119 of 260 patients (46%) had moderate disability or worse at 6 months, including 55 of 260 patients (21%) who were dead at 6-month follow-up. Death or severe disabilities were more commonly attributed to non-TBI causes while moderate disabilities or better were more commonly due to TBI. On adjusted analysis, an abnormal GCS score, higher Charlson Comorbidity Index scores, and the presence of traumatic intracranial hemorrhage on initial ED cranial imaging were associated with worse GOS-E scores at 6 months. Trauma center transport was not associated with GOS-E scores at 6 months for TBI patients and in patients with traumatic intracranial hemorrhage on initial ED CT imaging. CONCLUSIONS: In older adults with TBI, moderate disability or worse is common 6 months after injury. Over one in five of older adults with TBI died by 6 months, usually due to nonhead causes. Patients with TBI or traumatic intracranial hemorrhage did not have improved functional outcomes with initial triage to a trauma center.

Mortality After Traumatic Brain Injury in Elderly Patients: A New Scoring System.

BACKGROUND: Traumatic brain injury (TBI) remains a life-threatening condition characterized by growing incidence worldwide, particularly in the aging population, in which the primary goal of treatment appears to be avoidance of chronic institutionalization. METHODS: To identify independent predictors of 30-day mortality or vegetative state in a geriatric population and calculate an intuitive scoring system, we screened 480 patients after TBI treated at a single department of neurosurgery over a 2-year period. We analyzed data of 214 consecutive patients aged ≥65 years, including demographics, medical history, cause and time of injury, neurologic state, radiologic reports, and laboratory results. A predictive model was developed using logistic regression modeling with a backward stepwise feature selection. RESULTS: The median Glasgow Coma Scale (GCS) score on admission was 14 (interquartile range, 12-15), whereas the 30-day mortality or vegetative state rate amounted to 23.4%. Starting with 20 predefined features, the final prediction model highlighted the importance of GCS motor score (odds ratio [OR], 0.17; 95% confidence interval [CI], 0.09-0.32); presence of comorbid cardiac, pulmonary, or renal dysfunction or malignancy (OR, 2.86; 9 5% CI, 1.08-7.61); platelets ≤100 × 109 cells/L (OR, 13.60; 95% CI, 3.33-55.49); and red blood cell distribution width coefficient of variation ≥14.5% (OR, 2.91; 95% CI, 1.09-7.78). The discovered coefficients were used for nomogram development. It was further simplified to facilitate clinical use. The proposed scoring system, Elderly Traumatic Brain Injury Score (eTBI Score), yielded similar performance metrics. CONCLUSIONS: The eTBI Score is the first scoring system designed specifically for older adults. It could constitute a framework for clinical decision-making and serve as an outcome predictor. Its capability to stratify risk provides reliable criteria for assessing efficacy of TBI management.

Rapid Discharge After Interfacility Transfer for Mild Traumatic Intracranial Hemorrhage: Frequency and Associated Factors.

INTRODUCTION: Traumatic intracranial hemorrhage (TIH), brain injury with radiographic hemorrhage, is a common emergency department (ED) presentation, and encompasses a wide range of clinical syndromes. Patients with moderate and severe neurotrauma (Glasgow Coma Scale [GCS] < 13) with intracranial hemorrhage require care at a trauma center with neurosurgical capabilities. However, many patients with mild traumatic intracranial hemorrhage (mTIH), defined as radiographic bleeding and GCS ≥ 13, do not require operative intervention or intensive care unit monitoring, but are still routinely transferred to tertiary care centers. We hypothesized that a significant proportion of patients are managed non-operatively and are discharged within 24 hours of admission. METHODS: This was a retrospective, observational study of consecutive patients age ≥ 16 years, GCS ≥ 13 who were transferred to an urban, medical school-affiliated, 100,000 annual visit ED over a seven-year period with blunt isolated mTIH. The primary outcome was discharge within 24 hours of admission. We measured rates of neurosurgical intervention, computed tomography hemorrhage progression, and neurologic deterioration as well as other demographic and clinical variables. RESULTS: There were 1079 transferred patients with isolated mTIH. Of these, 92.4% were treated non-operatively and 35.8% were discharged within 24 hours of presentation to the tertiary ED. Patient characteristics associated with rapid discharge after transfer include a GCS of 15 (odds ratio [OR] 2.9, 95% confidence interval [CI], 1.9 - 4.4), subdural hematoma ≤ 6mm (OR 3.1, 95% CI, 2.2 - 4.5) or the presence of an isolated subarachnoid hemorrhage (OR 1.7, 95% CI, 1.3 - 2.4). Of patients with length of stay < 24 hours, 79.8% were discharged directly from the ED or ED observation unit. CONCLUSION: Patients transferred to tertiary care centers are frequently discharged after brief observation without intervention. Risk can be predicted by clinical and radiographic data. Further prospective research is required to determine a safe cohort of patients who could be managed at community sites.

Is There a Need for Platelet Transfusion After Traumatic Brain Injury in Patients on P2Y12 Inhibitors?

BACKGROUND: A significant portion of patients sustaining traumatic brain injury (TBI) are on antiplatelet medications. The reversal of P2Y12 agents after intracranial hemorrhage (ICH) remains unclear. The aim of our study is to evaluate outcomes after TBI in patients who are on preinjury P2Y12 inhibitors and received a platelet transfusion. METHODS: We analyzed our prospectively maintained TBI database from 2013 to 2016 and included all patients with isolated ICH who were on P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor). Regression analysis was performed adjusting for demographics and injury parameters. Outcome measures included progression of ICH, adverse discharge disposition (skilled nursing facility), and mortality. RESULTS: A total 243 patients with ICH on preinjury P2Y12 inhibitor met our inclusion criteria and were analyzed. Mean age was 55 ± 18 y, 58% were males and 60% were white and median injury severity score was 13 [9-18]. 73.6% received platelet transfusion after admission. The median packs of platelet transfusion were 1 [1-2] units. After controlling for confounders, patients who received platelet transfusion had a lower rate of progression (OR: 0.68, P = 0.01) and decreased rate of neurosurgical intervention (OR: 0.80, P = 0.03). Overall mortality was 12.3%. Patients on P2Y12 inhibitors who received platelet transfusion had lower odds of discharge to a skilled nursing facility (OR: 0.75, P = 0.02) and mortality (OR: 0.85, P = 0.04). CONCLUSIONS: Platelet transfusion after isolated traumatic ICH in patients on P2Y12 inhibitors is associated with improved outcomes. Platelet transfusion was associated with decreased risk of progression of ICH, neurosurgical intervention, and mortality. Further randomized studies to validate the use of platelet transfusion and define the optimal dose in patients on P2Y12 inhibitors are warranted.

Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission.

BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%-99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, -0.053-0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.