Elsevier

Surgery

Volume 148, Issue 4, October 2010, Pages 724-730
Surgery

Central Surgical Association
Antiplatelet agents, warfarin, and epidemic intracranial hemorrhage

Presented at the 67th Annual Meeting of the Central Surgical Association, Chicago, Illinois, March 2010.
https://doi.org/10.1016/j.surg.2010.07.014Get rights and content

Background

Atrial fibrillation prophylaxis with warfarin and strong antiplatelet agent use in cardiovascular diseases has increased the incidence of anticoagulation in the elderly. We studied traumatic intracranial hemorrhage (TICH) in patients ≥55 years of age on anticoagulation and antiplatelet agents in a stable population.

Methods

We used a Level 1 Trauma Center registry study comparing TICH in patients on anticoagulation drugs during the index periods 1999 to 2000 (T1) and 2007 to 2008 (T2).

Results

A total of 526 TICH patients were seen in T1 and T2 (age, 77.6 vs 77.5 years; not significant [NS]), with the rate doubling from 6.2% to 12.3% of all trauma activations (P < .01). There was no increase in atrial fibrillation, warfarin use, or CHADS2 scores in atrial fibrillation patients on anticoagulation therapy. TICH in patients taking antiplatelet agents increased 5-fold (2.2 % vs 10.3%; P < .01). Overall TICH mortality rate was the same (12.4% vs 12.2%, NS). TICH mortality among patients on therapeutic warfarin was greater in T1 (26%; P < .05), but mortality was similar to TICH in patients not on anticoagulants in T2 (19% vs 12.2%, NS), suggesting treatment improved. Prevalence and mortality of TICH in patients on antiplatelet agents were similar to TICH in patients on warfarin.

Conclusion

TICH in patients on anticoagulants is epidemic in patients ≥55 years of age. Despite national trends, our well-served population has not seen an increase in warfarin use for atrial fibrillation. Instead, use of antiplatelet agents has increased and is associated with an increased incidence of TICH.

Section snippets

Materials and methods

This study was approved by the Beth Israel Deaconess Medical Center Institutional Review Board before data collection and review. We reviewed our prospectively collected Trauma Registry database, examining the records of all patients admitted with intracranial hemorrhage in 2 time periods: 1999 to 2000 and 2007 to 2008. We also searched the hospital database for ICD-9-CM codes classifiable as TICH. All intracranial hemorrhages were considered traumatic if secondary to an identified external

Results

Of 5,371 trauma patients (T1, 2,230; T2, 3,141), 526 patients age ≥55 years with TICH were identified. In T1, 6.2% of traumas were TICH patients. This number doubled to 12.3% in T2 (P < .01; Fig 1). The mean age of the 2 groups was similar (77.6 years in T1 vs 77.5 years in T2). In T1, 48% of the patients were males; in T2, 49% of the patients were males (Table II).

The trauma mechanisms in T1 were 66% falls from standing, 12% falls down stairs, 4% falls from height, 6% pedestrians struck by a

Discussion

Anticoagulated patients are at increased risk of TICH after head injury. We see here that the incidence of TICH in our trauma population has doubled since the index period of 1999 to 2000. Our trauma center population, however, changed very little when comparing the rate of warfarin AC use for AF. The mortality and morbidity associated with this epidemic are substantial, and so it is important to understand it in better detail.

First, we sought to understand the reasons TICH patients had been

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