Introduction: Anticoagulant therapy (ACT) after traumatic intracranial hemorrhage may lead to hematoma expansion, but in the presence of thromboembolic events such as deep vein thrombosis (DVT) and pulmonary embolism (PE) or conditions such as atrial fibrillation, the clinician must decide if the benefits of ACT outweigh the risks. Currently, no data exist to guide therapy.
Methods: We retrospectively identified all patients admitted to our institution with traumatic intracranial hemorrhage that received intravenous heparin, full dose enoxaparin, or warfarin during their initial hospitalization over a three-year period. We reviewed their demographics, hospital course, ACT indication, timing of medication initiation relative to the trauma, and complications.
Results: A total of 74 patients were identified. The median age and GCS of these patients was 51 and 10, respectively. Twenty-two patients required neurosurgical procedures for their presenting injury including intracranial pressure (ICP) monitors and/or open surgeries. Fifty-four patients had DVTs or PEs prior to ACT, and the remaining 20 patients had pre-existing conditions or other indications for ACT.
The median time from injury to starting ACT was 8 days. Immediate complications, which included a new hemorrhage or previous hematoma progression, occurred in 6 (8.1%) patients, and none of these patients required a neurosurgical intervention. Delayed complications including progression of acute to chronic subdural hematoma (SDH) that required an operative intervention occurred in 2 (2.7%) patients, and one patient died from a delayed, acute hemorrhage.
Conclusions: For this patient population, the intracranial hemorrhage risk from ACT therapy must be weighed against the morbidity of delaying treatment for thromboembolic conditions. Although further studies are ongoing, our retrospective review provides the first complication rates in head trauma patients.
Patient Care: It will provide the first data on initiating anti-coagulant agents after traumatic intracranial hemorrhage which can be used to help guide clinicians in their decision making on appropriate timing for starting these agents after TBI.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify the rate of acute hemorrhagic complications associated with starting anti-coagulant agents within a certain time period after traumatic intracranial hemorrhage 2) Identify the rate of delayed hemorrhagic complications after initiating anti-coagulant therapy after traumatic intracranial hemorrhage