Eur J Trauma Emerg Surg DOI 10.1007/s00068-017-0793-7

ORIGINAL ARTICLE

The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy D. Scantling1   · C. Fischer1 · R. Gruner1 · A. Teichman1 · B. McCracken1 · J. Eakins2 

Received: 3 January 2017 / Accepted: 18 April 2017 © Springer-Verlag Berlin Heidelberg 2017

Abstract  Introduction Increasing active longevity has created an increasing surge of elderly trauma patients. The majority of these patients suffer blunt trauma and many are taking antithrombotic agents. The literature is mixed regarding the utility of routine repeat head CT in patients taking antithrombotic medications with a GCS of 15 and initial negative head CT. We hypothesized that scheduled delayed CT head 12 h after admission (D-CTH) in elderly blunt trauma victims would not identify clinically significant new hemorrhages or change management. Methods A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt head injuries from 2010 to 2012 was performed. By hospital protocol, all such patients on antithrombotic therapy receive a routine D-CTH. All of these patients were included. Demographics, injuries, medications, laboratory values, LOS, mental status, and management were analyzed. Results Of the 234 patients meeting inclusion criteria, 8 initially were identified as having D-ICH. Upon further review, five patients had the same findings on both initial and delayed CT scans and one patient was determined to actually have had a hemorrhage stroke. Ultimately, only

two patients (0.85%, 95% CI 0.1–3.1%) had new ICH discovered on D-CTH. None of the patients on warfarin demonstrated any new injury on D-CTH (95% CI ≤ 4.6%). Only one patient taking aspirin as a sole agent had a delayed injury on D-CTH (1.1%, 95% CI 0–4.2%). The remaining patient was taking a combination of aspirin and clopidogrel representing 2.2% of 45 patients on combination therapy (95% CI 0.1–11.8%). Only two patients taking a direct thrombin inhibitor (dabigatran) met inclusion criteria and neither endured a bleed (95% CI ≤ 77.6%). Further analysis revealed no cases with clinical changes or surgical intervention for new ICH on delayed imaging. No inference could be made to predict which patients would suffer D-ICH. Conclusions D-CTH in elderly trauma patients taking antithrombotic agents shows no statistically significant or clinical benefit for diagnosing delayed intracranial hemorrhage after minor head injury. In those with delayed imaging showing new ICH, management was not significantly altered. Not enough data were available to predict which patients would develop D-ICH, even if asymptomatic.

D. Scantling and C. Fischer have contributed in the capacity of first author.

Introduction

* D. Scantling [email protected]

Trauma is the primary cause of death in young Americans, but patient demographics are changing rapidly [1]. Baby boomers are now the fastest growing demographic in America. They represent over 12% of the population and will make up 20% in only a few decades [2, 3]. This demographic shift paired with an increasingly active and injury-prone lifespan represents a substantive challenge

1

Hahnemann University Hospital, Drexel University College of Medicine, 215 N 15th St MS 413, Philadelphia, PA 19102, USA

2

AtlantiCare Regional Medical Center, 1925 Pacific Avenue, Atlantic City, NJ 08401, USA





Keywords  Complications · Elderly · Outcome assessment · Traumatology · Head injury · Antithrombotics

13

D. Scantling et al.

to the healthcare system. Between 1993 and 2003, elderly falls increased 155% [4]. It is predicted that 30% of those 65 years or older will fall from standing each year and 4.5% of individuals over 70 years of age will die of those injuries [4]. The vast majority, some 75% of elderly who have fallen are not seriously injured [4]. Management of these seemingly minor injuries in this vulnerable age group is somewhat of a quandary, especially as objective data like vital signs can be unreliable in the elderly trauma population [4, 5]. Furthermore, a substantial percent of elderly Americans are believed to be at increased risk of bleeding with the use of an ever increasing array of antithrombotic agents for comorbid conditions. The US Department of Health and Human Services reports 6% of Americans aged 65–74 use one or more antithrombotics and 10% of patients over the age of 75 [6]. The number of available antithrombotic agents continues to rise, while development of their reversal agents has been slower and lagged behind. To date, means of evaluating for intracranial hemorrhage is primarily reliant on clinical examination and computed tomography (CT) of the head. Small bleeds not large enough to be seen on CT in the hyper-acute phase have potential to progress to life-threatening hemorrhage in the setting of antithrombotic use. The potential for delayed bleeding raises legitimate intuitive concern to delineate the minority of elderly fall victims who have suffered severe, even if occult, injury from those who did not. This has justified the need for delayed CT of the head in this patient population in many institutions, but so far has remained an unproven management strategy. We hypothesized that routine repeat head CT in the asymptomatic elderly taking antithrombotic medication would not identify clinically relevant delayed intracranial hemorrhage.

Methods A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt head injuries during a 24 month span from 2010 to 2012 was performed. Inclusion criteria consisted of all patients over the age of 65 with a GCS of 14 or 15, on antithrombotic therapy who were admitted to our level one trauma center and received both an initial and a delayed CT of the head (D-CTH). D-CTH was defined as a routine and scheduled head CT 12 h after admission without prompting by a change in clinical status. By hospital protocol, all patients aged 65 years or older who take an antithrombotic receive a routine, scheduled D-CTH approximately 12 h after admission. Exclusion criteria included those patients found to have findings of an intracranial injury on the initial CT. All CT scans were initially reviewed by

13

radiology residents and trauma surgery attendings with findings confirmed by attending neuroradiologists. Data collected included age, sex, comorbidities, concurrent injuries, medications, laboratory values, LOS, mental status, and management changes. One- and two-sided confidence intervals were created to evaluate findings.

Results Of the 268 patients initially identified in the trauma registry as having had blunt head injury and receiving a repeat CTH, 234 patients met inclusion criteria. 8 initially were identified as having D-ICH. Five of these patients were later excluded, because they were determined to have an intracranial injury that could be seen on the initial scan and one patient was excluded after it was determined that they actually had a hemorrhagic stroke. The remainder of those excluded were correctly identified on initial CTH to have had an ICH. Mean time to a scheduled second CT of the brain was 844 min (14 h) (Table 1). Of those meeting inclusion criteria, the mean age was 80 years, 43.5% were male, and 56.4% were female (Table 1). Fall from standing represented 80% of injury mechanisms followed Table 1  Demographics and outcomes of elderly blunt head injury victims with an initial negative head CT Demographic

Number

Total patients Mean age in years Male Female GCS 15 on arrival LOC reported D-CTH positive D-CTH changing management Mean time to D-CTH in minutes Antithrombotic used  Warfarin  Aspirin  Clopidogrel  Dabigatran  Other Average LOS in days Discharge destination  Home  Nursing facility  Rehabilitation  Died/hospice

234 80.9 43.5% 56.4% 88% 41% 0.85% 0 844

 Assisted living

63 176 34 2 4 4.86 62% 16.6% 14.1% 3.4% 2.9%

Percent

The role of delayed head CT in evaluation of elderly blunt head trauma victims taking…

90 80 70 60 50 40 30 20 10 0

Injury Mechanisms

injury (95% CI ≤ 22.1%). Average length of stay for all patients was 4.86 days. 62% were discharged home, 16.6% to skilled nursing homes, 14.1% to rehabilitation facilities, 3.4% died during the admission, and 2.9% were discharged to assisted living quarters (Table 1). Further analysis revealed no cases with neurologic changes or surgical intervention for new ICH on delayed imaging. Both patients with D-ICH had suffered a fall from standing with loss of consciousness, had normal coagulation profiles, and were treated with observation and ultimately discharged to either home or a rehabilitation facility after stays of 3 and 5 days. No pattern was identified to predict delayed bleeding on D-CTH.

80.4

8.5 Fall From Standing

5.9

Motor Vehicle Found Down Crash

4.3

0.9

Fall From Height

Assault

Mechanism of Injury

Fig. 1  Injury patterns by mechanism of the included elderly blunt head injury victims

Discussion

by motor vehicle crashes (8.5%), being “found down” (5.9%), falls from height (4.3%) and assault (0.9%) (Fig. 1). The most common additional injury, suffered by 26.1% of patients, was a head or facial laceration (Fig. 2). 41% of patients reported loss of consciousness. 12% of patients had a GCS of 14 and 88% had a GCS of 15 on arrival (Table 1). Only two patients had a new ICH demonstrated on D-CTH (0.85%, 95% CI 0.1–3.1%). Both patients were taking aspirin of a total of 176 patients taking aspirin alone or combination with another antithrombotic agent (1.1%, 95% CI 0.1–4.0%). Both patients also had a presenting GCS of 15. The one patient taking aspirin alone represented 1.1% of the 131 patients taking aspirin as solo therapy (95% CI 0–4.2%). The remaining patient was taking a combination of aspirin and clopidogrel representing 2.2% of 45 patients on combination therapy (95% CI 0.1–11.8%). None of the 63 patients on warfarin (95% CI ≤ 4.6%), two patients on direct thrombin inhibitors (95% CI ≤77.6%), or the 12 patients on solo clopidogrel therapy demonstrated a delayed

Blunt injuries and specifically falls comprise the vast majority of trauma in the elderly [7, 8]. As a direct result, several large-scale studies on the topic of blunt or overall trauma in elderly populations exist. Research has found that falls currently represent a large disease burden in elderly patients, with the rate of elderly falls increasing by 120% in the last decade [9]. Although traditional thinking suggested that outcomes in elderly may be much worse, recent studies suggest that timely and appropriate intervention may lead to outcomes comparable to younger patients [9]. As the aging population naturally has a higher number of comorbidities, elderly trauma patients on antithrombotic medication are frequently encountered at our institution. Our survey of current literature shows a gap in knowledge regarding the most appropriate management of elderly patients on antithrombotics with minor head trauma. It has been well established that pre-injury antithrombotic medication can lead to worse outcomes in elderly patients,

Specific Injury Paerns with Ini al Nega ve CT-H

Fig. 2  Concomitant injuries of elderly patients suffering blunt head injury with an initial negative head CT

30

26.1

Percent

25 20 15 10

6.8

6.4

6.0

6.0

6.0

5 0

5.6

3.0

1.7

0.4

Injury Type

13

D. Scantling et al.

leading to protocols at many institutions, including ours, that require repeat head imaging to detect delayed intracranial bleed [10]. However, until this study, it has not been established if repeat head CT will truly change the management of this growing population of elderly patients taking antithrombotic medications. Repeat CT imaging in the elderly patient taking antithrombotic medication with blunt head trauma largely stems from research that establishes poor outcomes in elderly patients taking antithrombotics who suffer head injuries. Although the majority of intracranial bleeding in patients on antithrombotics is spontaneous, trauma may provoke a bleed that once occurs and has a mortality of 20–50% [11]. Thus, several studies have established poor outcomes in patients taking antithrombotics. Lavoie et al. showed that patients anticoagulated with warfarin suffered more severe head injuries and a higher rate of mortality (40 vs 21%) even when adjusted for comorbidities and mechanism of injury [12]. Peck et al. found that patients taking antithrombotic agents were more likely to show progression of initial hemorrhage and to develop new hemorrhagic focus [10]. Subsequent studies found incidence of delayed intracranial hemorrhage in patients taking antithrombotic agents suffering minor head trauma, such as falls [13]. A study by Tauber et al. identified a delayed hemorrhage rate of 4% with only 81 mg aspirin use. More importantly, two of these delayed bleeds resulted in craniotomy and one patient died [13]. Their findings suggested that initially negative CT scans should be followed with either a repeat head CT at 24 or 48 h of observation [13]. It was this study in particular that spurred our institution’s protocol change to routinely perform D-CTH. Utilizing a scheduled and routine repeat head CT at approximately 12 h post initial CT is the protocol that has been adopted at our institution to evaluate for delayed intracranial hemorrhage. However, in our experience, repeat CT after an initial negative study in patients taking antithrombotics with minor head trauma has proved to be of little clinical value. Other trauma centers have had similar experiences, leading to several studies examining delayed ICH and repeat imaging [13–17]. In a retrospective 2011 study, Peck et al. studied the incidence of delayed intracranial hemorrhage in a trauma population admitted between 2006 and 2009. Similar to our institution, patients on antithrombotics suffering from blunt head trauma were managed with a protocol evaluating for delayed intracranial hemorrhage with a repeat head CT. Unlike our institution, the repeat head CT in this study was performed at 6 h after the first. These authors hypothesized that the incidence of delayed ICH on repeat head CT would be zero in patients with negative initial CT and an unchanged neurological exam [14]. They included patients

13

on warfarin and clopidogrel or a combination of the two. Out of 500 patients, 85% had an initial negative CT. As per the hospital protocol, these patients received a repeat head CT 6 h later [14]. Only 1% of the patients were found to have a positive or equivocal repeat CT, and none of these patients required surgical intervention or had any change in neurological exam [14]. Although the mean age of the patients in this study was 75, the authors did not restrict their study population to those over the age of 65 [14]. Thus, although this study produced results that support those found in our study, they cannot address the elderly population specifically. Kaen et al. addressed the use of sequential CT scans in patients taking antithrombotics suffering minor head trauma in a 2005 prospective study. They included patients with initial negative head CT, and repeated the CT at 24 h after the first. Antithrombotics were not stopped or reversed in any of the patients with negative initial CT and GCS of 14–15 [15]. They found that only two patients (1.4%) showed delayed intracranial bleeding on repeat CT [15]. Although only two patients is not enough to sufficiently power statistical comparisons, the authors did note that these two patients were among a smaller subgroup of patients that were on antithrombotics, and additionally suffered loss of consciousness after head injury [15]. The conclusions reached in this study support the findings in our study: repeat CT following blunt head injury in patients taking antithrombotic agents has little clinical value, although 24 h observation may be warranted. Nishijima et al. prospectively studied 1064 blunt head injury patients from 2009 to 2011, examining the incidence of immediate and delayed intracranial hemorrhage in patients taking warfarin and clopidigrel. Despite finding an increased incidence of immediate intracranial hemorrhage in patients taking clopidigrel, the authors found a 0% incidence of delayed intracranial hemorrhage [16]. The incidence of delayed ICH in the warfarin group was also low, at 0.6% [16]. Based on these clinical findings, repeat CT is unlikely to show changes that will impact clinical management of trauma patients taking antithrombotics. The cost burden of unnecessary repeat CT is significant. Stein et al. preformed a cost analysis in 2005 that examined the cost of CT compared to other management for head injury. The results of the study showed that CT scanning as a screening test was still more cost effective than treatment for a missed head bleed or prolonged inpatient stay [18]. However, given the results of this study, repeat head CT may be avoided without fear of missing a delayed ICH. Cost analysis aside, CT scans remain expensive and may be unnecessary tests in this population. Blunt head injuries in the elderly can have a significant impact on post-injury functioning [19, 20]. We feel

The role of delayed head CT in evaluation of elderly blunt head trauma victims taking…

that eliminating routine repeat head CT after minor head trauma will not miss any clinically significant ICH. It has been well established in head injuries that findings on clinical exam are excellent predictors of need for CT [21]. We feel that a short period of observation and repeated neurological exam should be sufficient in this population. In addition, our study is the first to our knowledge that has addressed repeat CT in the elderly trauma population specifically. We feel that it is especially important to the address these clinical questions in the elderly as this demographic is identified as high risk in the New Orleans Criteria, The Canadian Head CT Rule, and the NEXUS II Rule [21–23]. It is worth noting that the time frame of 12 h followup, as opposed to 6 h used in several other studies, may have led D-CTH being read by a different radiologist than the initial CT at the time of trauma. This may be to blame for our five patients who had different reads on review for the purpose of this study and, therefore, were not included in the final analysis. As such, our study may have been more apt to identify missed injury than new head bleeds. These patients were, at the time, managed as if they had a delayed bleed and, like our two patients who actually did, suffered no ill effects or change in neurologic status. Keeping the routine D-CTH within the shift of the same staff radiologist potentially would have prevented costly ICU stays for these patients but would not have changed their clinical course. It is unclear if the results found in this study can be extended to patients taking newer antithrombotics such as direct thrombin or factor Xa inhibitors such as rivaroxaban or apixaban. Little data exist about delayed ICH with these agents despite their growing popularity. Establishing appropriate trauma management protocols for these agents should be a priority of research in trauma patients moving forward. While we did not capture any clinically significant delayed bleeds in our study, further higher powered research may help identify patterns in patient populations predisposing them to delayed bleeds that could be clinically significant with different antithrombotics or injury profiles. Compliance with ethical standards  Conflict of interest  There are no conflicts of interest to disclose for Dane Scantling, Chelsea Fischer, Ryan Gruner, Amanda Teichman, Brendan McCracken, and James Eakins. Research involving human participants and/or animals This research involved was conducted in compliance with all international ethical standards and was approved by our institutional review board. All ethical standards were met. This study did not involve experimental intervention and there was no mechanism to cause harm to patients.

Informed consent  This study was retrospective in nature. Our institutional review board determined that consent was not necessary and all identities were fully protected.

References 1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based injury statistics query and reporting system (WISQARS) [online]. (2005). Available from URL: www.cdc.gov/ncipc/wisqars. Accessed 17 Dec 2013. 2. United States Census Bureau. Age groups and sex 2008. Washington: United States Census Bureau; 2008. 3. DCLonner J, Koval K. Polytrauma in the elderly. Clin Orthop Relat Res. 1995;318:136–43. 4. Spaniolas K, Cheng JD, Gestring ML, Sangosanya A, Stassen NA, Bankey PE. Ground level falls are associated with significant mortality in elderly patients. J Trauma Inj Infect Critical Care. 2010;69(4):821. 5. Heffernan DS, Thakkar RK, Monaghan SF, Ravindran R, Adams CA Jr, Kozloff MS, Gregg SC, Connolly MD, Machan JT, Cioffi WG. Normal presenting vital signs are unreliable in geriatric blunt trauma victims. J Trauma. 2010;69(4):813–20. 6. Patel VI, Thadepalli H, Mandal AK. Thoracoabdominal injuries in the elderly: 25 years of experience. J Natl Med Assoc. 2004;96(12):1553–7. 7. U.S spends nearly $1 billion on blood thinners for adults: Research Activities, January 2010, No. 353. Agency for Healthcare Research and Quality. Rockville, MD. http://archive.ahrq. gov/news/newsletters/research-activities/jan10/0110RA1.html. 8. Chu I, Vaca F, Stratton S, Chakravarthy B, Hoonpongsimanont W, Lotifpour S. Geriatric trauma care: challenges facing emergency medical services. Cal J Emerg Med. 2007;8(2):51–5. 9. Mak CH, Wong SK, Wong GK, Ng S, Wang KK, Lam PK, Poon WS. Traumatic brain injury in the elderly: is it as bad as we think? Curr Transl Geriatr Exp Gerontol Rep. 2012;1(3):171–8. 10. Peck KA, Calvo RY, Schechter MS, Sise CB, Kahl JE, Shackford MC, Shackford SR, Sise MJ, Blaskiewicz DJ. The impact of preinjury anticoagulants and prescription antiplatelet agents on outcomes in older patients with traumatic brain injury. J Trauma Acute Care Surg. 2014;76(2):431–6. 11. Hylek EM, Singer DE. Risk factors for intracranial hem orrhage in outpatients taking warfarin. Ann Intern Med. 1994;120(11):897–902. 12. Lavoie A, Ratte S, Clas D, Demers J, Moore L, Martin M, Bergeron E. Preinjury warfarin use among elderly patients with closed head injuries in a trauma center. J Trauma Acute Care Surg. 2004;56(4):802–7. 13. 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. 14. Peck KA, Sise CB, Shackford SR, Sise MJ, Calvo RY, Sack DI, Walker SB, Schechter MS. 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. 15. Kaen A, Jimenez-Roldan L, Arrese I, Delgado MA, Lopez PG, Alday R, Alen JF, Lagares A, Lobato RD. 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.

13

D. Scantling et al. 16. Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF. 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. 17. Docimo S, 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. 18. Stein SC, Burnett MG, Glick HA. Indications for CT scanning in mild traumatic brain injury: a cost-effectiveness study. J Trauma Acute Care Surg. 2006;61(3):558–66. 19. Mina AA, Knipfer JF, Park DY, Bair HA, Howells GA, Bendick PJ. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma Acute Care Surg. 2002;53(4):668–72.

13

20. Narum S, Brørs O, Stokland O, Kringen MK. Mortality among head trauma patients taking preinjury antithrombotic agents: a retrospective cohort analysis from a Level 1 trauma centre. BMC Emerg Med. 2016;16(1):29. 21. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100–5. 22. Stiell IG, Wells GA, The VK, Canadian CT, et al. Head rule for patients with minor head injury. Lancet. 2001;357:1391–6. 23. Mower WR, Hoffman JR, Herbert M, et al. NEXUS II investigators. Developing a decision instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005;59:954–9.