Management Strategies and Outcomes of Hemorrhagic Traumatic Brain Injury on Oral Anticoagulants

Introduction: Traumatic brain injury (TBI) is common, and the frequency of patients taking oral anticoagulants is increasing. However the optimal initial triage, management, and long term care plans of hemorrhagic TBI patients taking oral anticoagulants is not clear. Objectives: To determine the usage pattern of reversal agents for hemorrhagic TBI patients taking oral anticoagulants, and examine their characteristics and outcomes as compared to hemorrhagic TBI patients not taking these medications. Methods: This was a single-center, retrospective, observational study. Included were adults with trauma categorization and traumatic intracranial hemorrhage (ICH) between April 1, 2017 and December 31, 2019. Patient age, type of ICH, initial Glasgow Coma Scale (GCS) score, oral anticoagulant prescribed pre-injury, anticoagulation reversal agent given, and hospital discharge disposition were recorded. Results: For the entire sample size (n=111), the mean age and GCS were 71.6 years old and 13.8, respectively. Compared to patients not taking oral anticoagulants, patients taking oral anticoagulants were older (76.7 years old versus 69.1; p<0.01), had similar GCS scores (13.7 versus 13.9; p=0.69), had fewer subarachnoid hemorrhages (18.9% versus 37.8%; p=0.04), were less likely to discharge home (48.6% versus 73.0%; p=0.01), and had similar incidence of mortality (13.5% versus 6.7%; p=0.30). A total of 14/37 (37.8%) patients taking oral anticoagulants received reversal agents in the emergency department. Compared to patients taking oral anticoagulants and not given reversal agents, patients taking oral anticoagulants and given reversal agents had similar ages (78.8 years old versus 75.4; p=0.41), had similar GCS scores (12.9 versus 14.1; p=0.17), had similar ICH types (all p=1.0), were less likely to discharge home (48.6% versus 73.0%; p=0.01), and had higher incidence of mortality (28.6% versus 4.2%; p=0.05). Conclusions: This limited data set did not show improved outcomes by giving reversal agents to hemorrhagic TBI patients taking oral anticoagulants. However, until more robust data is available, judicious use of reversal agents in this high-risk patient population should remain common practice.