Markella Markou1,2, Burkhard Pleger3, Martin Grözinger4, Bogdan Pintea5, Uwe Hamsen6, Sabrina Könen5, Thomas A Schildhauer6, Ramón Martínez5, Konstantinos Gousias7,8,9. 1. Department of Neurology and Psychotraumatology, BG Hospital Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany. 2. Medical School, Rheinische Friedrich-Wilhelms University of Bonn, Sigmund Freud 25, 53127, Bonn, Germany. 3. Department of Neurology, BG Bergmannsheil University Hospital Bochum, Bürkle de la Camp Platz 1, 44789, Bochum, Germany. 4. Department of Radiology, BG Bergmannsheil University Hospital Bochum, Bürkle de la Camp Platz 1, 44789, Bochum, Germany. 5. Department of Neurosurgery and Neurotraumatology, BG Bergmannsheil University Hospital Bochum, Bürkle de la Camp Platz 1, 44789, Bochum, Germany. 6. Department of General Surgery and Trauma Surgery, BG Bergmannsheil University Hospital Bochum, Bürkle de la Camp Platz 1, 44789, Bochum, Germany. 7. Medical School, Rheinische Friedrich-Wilhelms University of Bonn, Sigmund Freud 25, 53127, Bonn, Germany. kostasgousias@yahoo.com. 8. Department of Neurosurgery and Neurotraumatology, BG Bergmannsheil University Hospital Bochum, Bürkle de la Camp Platz 1, 44789, Bochum, Germany. kostasgousias@yahoo.com. 9. Department of Neurosurgery, St Marien Academic Hospital Lünen, University of Münster, Altstadtstr. 23, 44534, Lünen, Germany. kostasgousias@yahoo.com.
Abstract
PURPOSE: Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited. METHODS: We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants. RESULTS: 71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation. CONCLUSIONS: Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.
PURPOSE: Novel oral anticoagulants are increasingly replacing vitamin K antagonists in the prophylaxis of thromboembolism as they are associated with lower incidence of spontaneous intracerebral hematomas and they do not require drug level monitoring. However, management dilemmas are apparent in patients on novel oral anticoagulants who have developed intracerebral hematomas after traumatic brain injury, since clinical experience with their reversal strategies is limited. METHODS: We retrospectively studied 90 patients with traumatic intracerebral hematomas undergoing treatment at the surgical intensive care unit of the BG University Clinic Bergmannsheil in Bochum between 2015 and 2018. We analyzed potential prognostic factors for their radiological (expansion of intracerebral hematoma) and clinical (patients' outcome) course, in particular the role of novel oral anticoagulants. RESULTS: 71.1% of patients were male; mean age was 67.3 years. Hematoma's expansion occurred in 35.9% of our patients, whereas 62.2% of our cohort showed a favorable outcome, defined as Glasgow Outcome Scale 4 and 5. Intake of novel oral anticoagulants was associated with a higher rate of hematoma's expansion compared to patients on vitamin K antagonists (p = 0.05) or to patients with normal coagulation status (p = 0.002). A younger age (p < 0.001) was identified as the sole independent prognostic factor for a more favorable outcome, after excluding our cases, who underwent a cardiopulmonary resuscitation. CONCLUSIONS: Our data showed a higher rate of hematoma's expansion in patients with traumatic intracerebral hematomas on novel oral anticoagulants vs. vitamin K antagonists and recommend the consideration of prophylactic reversal of the novel oral anticoagulants at admission. Larger prospective trials are warranted to conclude whether the current specific reversal protocols are safe and effective.
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