Hemorrhagic risk and intracranial complications in patients with minor head injury (MHI) taking different oral anticoagulants

Published:December 03, 2018DOI:


      The correlation between direct oral anticoagulants (DOACs) or Vitamin K Antagonist (VKAs) intake and the incidence of intracranial complications after minor head injury (MHI) is still object of debate: preliminary observation seems to demonstrate lower incidence in intracranial bleeding complications (ICH) in patients taking DOACs than VKA. METHODS. This prospective and observational study was performed to clarify the incidence of ICH in patients in DOACs compared to VKAs. Between January 2016 and April 2018 we have recorded in our ED patients with MHI taking oral anticoagulants. Their hemorragic risk score was calculated and recorded for each patient (Has Bled, Atria and Orbit). RESULTS A total of 402 patients with MHI taking anticoagulant were collected: 226 were receiving one of the four DOACs (dabigatran, rivaroxaban, apixaban or edoxaban) while 176 patients were in therapy with VKA. The rate of intracranial complications was significantly lower in patients receiving DOACs than in patients treated with VKA (p < 0.01). In the VKA group two patients died because of intracranial bleeding. No deaths were recorded in the DOACs group. DISCUSSION patients with MHI who take DOACs have a significant lower incidence of intracranial bleeding complications than those treated with vitamin k antagonists. This statement is supported by the observation that the hemorrhagic risk, measured according to the chosen scores, was similar between the two groups.


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        • Riccardi A.
        • Spinola B.
        • Minuto P.
        • Ghinatti M.
        • Guiddo G.
        • Malerba M.
        • et al.
        Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs).
        Am J Emerg Med. 2017; 35: 1317-1319
        • Connoly S.J.
        • Ezekowitz M.D.
        • Yusuf S.
        • Eikelboom J.
        • Oldgren J.
        • Parekh A.
        • et al.
        Dabigratan versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2009; 361: 1139-1151
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • Pan G.
        • Singer D.E.
        • Hacke W.
        • et al.
        Rivaroxaban versus warfarin in non valvular atrial fibrillation.
        N Engl J Med. 2011; 365: 883-891
        • Granger C.B.
        • Alexander J.H.
        • McMurray J.J.
        • Lopes R.D.
        • Hylek E.M.
        • Hanna M.
        • et al.
        Apixaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2011; 365: 981-992
        • Giugliano R.P.
        • Ruff C.T.
        • Braunwald E.
        • Murphy S.A.
        • Wiviott S.D.
        • Halperin J.L.
        • et al.
        Edoxaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2013; 369: 2093-2104
        • Sterne J.A.
        • Bodalia P.N.
        • Bryden P.A.
        • Davies P.A.
        • López-López J.A.
        • Okoli G.N.
        • et al.
        Oral anticoagulants for primary prevention, treatment and secondary prevention of venous thromboembolic disease, and for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis and cost-effectiveness analysis.
        Health Technol Assess. 2017; 21: 1-386
        • Lip G.Y.
        • Frison L.
        • Halperin J.L.
        • Lane D.A.
        Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol concomitantly) score.
        J Am Coll Cardiol. 2011; 57: 173-180
        • Fang M.C.
        • Go A.S.
        • Chang Y.
        • Borowsky L.H.
        • Pomernacki N.K.
        • Udaltsova N.
        Singer DE. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study.
        J Am Coll Cardiol. 2011; 58: 395-401
        • O'Brien E.C.
        • Simon D.N.
        • Thomas L.E.
        • Hylek E.M.
        • Gersh B.J.
        • Ansell J.E.
        • et al.
        The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation.
        Eur Heart J. 2015; 36 ([Epub 2015 Sep 29]): 3258-3264
        • Shoeb M.
        • Fang M.C.
        Assessing bleeding risk in patients taking anticoagulants.
        J Thromb Thrombolysis. 2013; 35: 312-319
        • Avezum A.
        • Lopes R.D.
        • Schulte P.J.
        • Lanas F.
        • Gersh B.J.
        • Hanna M.
        • et al.
        Apixaban in comparison with warfarin in patients with atrial fibrillation and Valvular heart disease: findings from the Apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) trial.
        Circulation. 2015 Aug 25; 132: 624-632
        • Ruff C.T.
        • Giugliano R.P.
        • Antman E.M.
        • et al.
        Evaluation of the novel factor Xa inhibitor edoxaban compared with warfarin in patients with atrial fibrillation: design and rationale for the effective aNticoaGulation with factor xA next GEneration in atrial fibrillation-thrombolysis in myocardial infarction study 48 (ENGAGE AF-TIMI 48).
        Am Heart J. 2010; 160: 635-641
        • Ezekowitz M.D.
        • Nagarakanti R.
        • Noack H.
        • Brueckmann M.
        • Litherland C.
        • Jacobs M.
        • et al.
        Comparison of dabigatran and warfarin in patients with atrial fibrillation and Valvular heart disease: the RE-LY trial (randomized evaluation of long-term anticoagulant therapy).
        Circulation. 2016; 134: 589-598
        • Bansilal S.
        • Bloomgarden Z.
        • Halperin J.L.
        • Hellkamp A.S.
        • Lokhnygina Y.
        • Patel M.R.
        • et al.
        Steering Committee and Investigators. Efficacy and safety of rivaroxaban in patients with diabetes and nonvalvular atrial fibrillation: the rivaroxaban once-daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation (ROCKET AF trial).
        Am Heart J. 2015; 170: 675-682.e8
        • Li X.S.
        • Deitelzweig S.
        • Keshishian A.
        • Hamilton M.
        • Horblyuk R.
        • Gupta K.
        • et al.
        Effectiveness and safety of apixaban versus warfarin in non-valvular atrial fibrillation patients in "real-world" clinical practice. A propensity-matched analysis of 76,940 patients.
        Thromb Haemost. 2017; 117: 1072-1082
        • Umei M.
        • Kishi M.
        • Sato T.
        • Shindo A.
        • Toyoda M.
        • Yokoyama M.
        • et al.
        Indications for suboptimal low-dose direct oral anticoagulants for non-valvular atrial fibrillation patients.
        J Arrhythm. 2017; 33: 475-482
        • Inohara T.
        • Xian Y.
        • Liang L.
        • Matsouaka R.A.
        • Saver J.L.
        • Smith E.E.
        • et al.
        Association of Intracerebral Hemorrhage among Patients Taking non-Vitamin K Antagonist vs vitamin K antagonist Oral anticoagulants with in-hospital mortality.
        JAMA. 2018; 319: 463-473
        • Almutairi A.R.
        • Zhou L.
        • Gellad W.F.
        • Lee J.K.
        • Slack M.K.
        • Martin J.R.
        • et al.
        Effectiveness and safety of non-vitamin K antagonist Oral anticoagulants for atrial fibrillation and venous thromboembolism: a systematic review and meta-analyses.
        Clin Ther. 2017; 39: 1456-1478.e36
        • Schulman S.
        • Kearon C.
        Subcommittee on control of anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients.
        J Thromb Haemost. 2005; 3: 692-694
        • Schulman S.
        • Beyth R.J.
        • Kearon C.
        • Levine M.N.
        Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition).
        Chest. 2008; 133: 257S-298S
        • Xian Y.
        • O'Brien E.C.
        • Liang L.
        • Xu H.
        • Schwamm L.H.
        • Fonarow G.C.
        • et al.
        Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation.
        JAMA. 2017 Mar 14; 317: 1057-1067
        • Riccardi A.
        • Frumento F.
        • Guiddo G.
        • Spinola M.B.
        • Corti L.
        • Minuto P.
        • et al.
        Minor head injury in the elderly at very low risk: a retrospective study of 6 years in an emergency department (ED).
        Am J Emerg Med. 2013; 31: 37-41
        • M1 Zeeshan
        • Jehan F.
        • O'Keeffe T.
        • Khan M.
        • Zakaria E.R.
        • Hamidi M.
        • et al.
        The novel oral anticoagulants (NOACs) have worse outcomes compared to warfarin in patients with intracranial hemorrhage after TBI.
        J Trauma Acute Care Surg. 2018;
        • Prexl O.
        • Bruckbauer M.
        • Voelckel W.
        • Grottke O.
        • Ponschab M.
        • Maegele M.
        • et al.
        The impact of direct oral anticoagulants in traumatic brain injury patients greater than 60-years-old.
        Scand J Trauma Resusc Emerg Med. 2018; 26: 20