Yaşar ÇATAL, Müge GÜNALP, Sinan GENÇ, Ahmet Burak OĞUZ, Ayça KOCA, Onur POLAT

Antikoagülan ve/veya Antiplatelet Tedavi Kullanan Hafif Kafa Travmalı Hastalarda Başlangıçta Normal olan Bilgisayarlı Kafa Tomografisini Tekrarlamamız Gerekir mi?

Amaç: Antikoagülan ve/veya antiplatelet (AC/AP) ilaç kullanan hastalarda kafa travması sonrası intrakraniyal kanama (İKK) riski yüksektir ve güncel kılavuzlar bu hastalar için bilgisayarlı kafa tomografisi (BT) görüntülemesini önermektedir. Başlangıçta normal kafa BT'si olan ve AC/AP ilaçları kullanan hafif kafa travmalı hastalar için yönetim önerileri konusunda fikir birliği yoktur. Bu çalışmanın amacı, başlangıçta normal kafa BT'si olan ve AC/AP kullanan hafif kafa travmalı hastalarda 24 saatlik bir gözlem sonrasında gecikmiş İKK oranını belirlemektir. Metod: AC/AP ilaç kullanan, 18 yaş ve üzeri hafif kafa travmalı hastalar prospektif olarak çalışmaya alındı. Hastalara kanama şüphesi nedeniyle kafa BT’si çekildi. Çekilen ilk kafa BT'si normal olan hastalara gecikmiş intrakraniyal kanamayı saptamak için 24 saatlik gözlem süresi sonrasında tekrar kafa BT görüntülemesi yapıldı. Bulgular: Toplam 101 hasta çalışmaya dahil edildi ve hastaların %57,4'ü (n=58) kadındı. 24 saatlik gözlem sonrasında hastaların %2,9'unda (n=3) gecikmiş İKK saptandı. Gecikmiş İKK'li hastaların hiçbirinde cerrahi tedavi veya başka girişim gerekmedi. Gecikmiş İKK, asetilsalisilik asit (n=1), dabigatran (n=1) ve apiksaban (n=1) kullanan hastalarda saptandı. Sonuç: AC/AP kullanan hafif kafa travmalı hastalarda gecikmiş İKK nadirdir ve klinik olarak önemli olmayabilir. Başlangıçta kafa BT'si normal olan, AC/AP ilaç kullanan hafif kafa travması olan hastalarda 24 saatlik gözlemden sonra kafa BT görüntülemesinin tekrarı gerekli olmayabilir.

Anahtar Kelimeler:

Antikoagülan ilaçlar, antiplatelet ilaçlar, kafa travması, intrakraniyal kanama

Do We Need to Repeat the Initially Normal Head Computerized Tomography for Patients with Mild Head Trauma Using Anticoagulant and/or Antiplatelet Therapy?

Objective: Patients using anticoagulant and/or antiplatelet (AC/AP) medications are at an increased risk of intracranial hemorrhage (ICH) subsequent to head trauma and current guidelines recommend a head computed tomography (CT) scan for these patients. There is a lack of consensus about management recommendations for mild head trauma patients on AC/AP treatment who had an initially normal head CT. The aim of this study was to determine the rate of delayed ICH after a 24-hour observation in patients with mild head trauma using AC/AP who had an initially normal head CT. Method: Patients aged 18 and older, using AC/AP drugs with mild head trauma were included prospectively. Patients underwent head CT for suspected bleeding. A repeat CT scan was performed after a 24-hours observation period for the patients who had an initially normal head CT for detecting delayed intracranial hemorrhage. Result: A total of 101 patients were included and, 57.4% (n=58) of the patients were female. Delayed ICH was detected in 2.9% (n=3) of the patients after a 24-hour observation. None of the patients with delayed ICH needed surgical treatment or further intervention. Delayed ICH was found in patients who used acetylsalicylic acid (n=1), dabigatran (n=1), and apixaban (n=1). Conclusion: In patients with mild head trauma using AC/AP, delayed intracranial hemorrhage is rare and may be clinically insignificant. A repeat CT scanning after 24-hour observation may not be necessary for patients with mild head trauma using AC/AP therapy who had initially normal head CT.

Keywords:

Anticoagulant drugs, antiplatelet drugs, head trauma, intracranial hemorrhage,

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1. Pearson WS, Sugerman DE, McGuire LC, Coronado VG. Emergency department visits for traumatic brain injury in older adults in the United States: 2006-08. West J Emerg Med. 2012;13(3):289-93.
2. Marin JR, Weaver MD, Yealy DM, Mannix RC. Trends in visits for traumatic brain injury to emergency departments in the United States. JAMA. 2014; 311(18): 1917-9.
3. Robert-Ebadi H, Le Gal G, Righini M. Use of anticoagulants in elderly patients: practical recommendations. Clin Interv Aging. 2009;4:165.
4. Campiglio L, Bianchi F, Cattalini C, et al. Mild brain injury and anticoagulants: Less is enough. Neurol Clin Pract. 2017;7(4):296-305.
5. Kaen A, Jimenez-Roldan L, Arrese I, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma Acute Care Surg. 2010;68(4):895-8.
6. McCammack KC, Sadler C, Guo Y, Ramaswamy RS, Farid N. Routine repeat head CT may not be indicated in patients on anticoagulant/antiplatelet therapy following mild traumatic brain injury. West J Emerg Med. 2015;16(1):43-9.
7. Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med. 2012;59(6):451-5.
8. Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med. 2012;59(6):460-8.
9. Peck KA, Sise CB, Shackford SR, et al. Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma Acute Care Surg. 2011;71(6):1600-4.
10. Schoonman GG, Bakker DP, Jellema K. Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization. Eur J Neurol. 2014;21(7):1021-5.
11. Tauber M, Koller H, Moroder P, Hitzl W, Resch H. Secondary intracranial hemorrhage after mild head injury in patients with low-dose acetylsalicylate acid prophylaxis. J Trauma Acute Care Surg. 2009;67(3):521-5.
12. Jagoda AS, Bazarian JJ, Bruns Jr JJ, et al. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. J Emerg Nurs. 2009;35(2):e5-e40.
13. National Clinical Guideline Centre (UK). Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Children, Young People and Adults. London: National Institute for Health and Care Excellence (UK); 2014. 14. The Committee on Trauma. Advanced Trauma Life Support® Student Course Manual. Chicago: American College of Surgeons; 2018.
15. Riccardi A, Spinola B, Minuto P, 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(9):1317-9.
16. Verschoof MA, Zuurbier CC, de Beer F, Coutinho JM, Eggink EA, Van Geel BM. Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study and meta-analysis. J Neurol. 2018;265(2):315-21.
17. Huang GS, Dunham CM, Chance EA, Hileman BM. Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis. Am J Surg. 2020; 220 (1):55-61.
18. Kobayashi L, Barmparas G, Bosarge P, et al. Novel oral anticoagulants and trauma: the results of a prospective American Association for the Surgery of Trauma Multi-Institutional Trial. J Trauma Acute Care Surg. 2017;82(5):827-35.
19. Uccella L, Zoia C, Perlasca F, Bongetta D, Codecà R, Gaetani P. Mild traumatic brain injury in patients on long-term anticoagulation therapy: do they really need repeated head CT scan? World Neurosurg. 2016;93:100-3.
20. Mann N, Welch K, Martin A, et al. Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall. BMC Emerg Med. 2018;18(1):1-7.
21. Barmparas G, Kobayashi L, Dhillon NK, et al. The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: a two-center study. Am J Surg. 2019;217(6):1051-4.
22. Chenoweth JA, Gaona SD, Faul M, Holmes JF, Nishijima DK. Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surg. 2018;153(6):570-5.
23. Fuller GW, Evans R, Preston L, Woods HB, Mason S. Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review. Ann Emerg Med. 2019;73(1):66-75.
24. Swap C, Sidell M, Ogaz R, Sharp A. Risk of delayed intracerebral hemorrhage in anticoagulated patients after minor head trauma: the role of repeat cranial computed tomography. Perm J. 2016;20(2):14-6.
25. Dunham CM, Hoffman DA, Huang GS, Omert LA, Gemmel DJ, Merrell R. Traumatic intracranial hemorrhage correlates with preinjury brain atrophy, but not with antithrombotic agent use: a retrospective study. PLoS One. 2014;9(10):1-8.
26. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma Acute Care Surg. 2007;63(3):525-30.
27. Valiuddin H, Alam A, Calice M, et al. Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury. J Emerg Med. 2020;58(2):183-90.
28. Docimo S Jr., Demin A, Vinces F. Patients with blunt head trauma on anticoagulation and antiplatelet medications: can they be safely discharged after a normal initial cranial computed tomography scan? Am Surg. 2014;80(6):610-3.
29. Afaneh A, Ford J, Gharzeddine J, Mazar A, Hayward RD, Buck J. Head injury on Warfarin: likelihood of delayed intracranial bleeding in patients with negative initial head CT. BMC Res Notes. 2018;11(1):1-5.
30. Velmahos GC, Gervasini A, Petrovick L, et al. Routine repeat head CT for minimal head injury is unnecessary. J Trauma Acute Care Surg. 2006;60(3):494-501.

ISSN: 1309-3878
Yayın Aralığı: 3
Başlangıç: 2009
Yayıncı: Düzce Üniversitesi Tıp Fakültesi Aile Hekimliği AD adına Yrd.Doç.Dr.Cemil Işık Sönmez