Management des Schädel-Hirn-Traumas unter Therapie mit direkten oralen Antikoagulantien : eine retrospektive Studie

Einleitung: Die Anzahl der PatientInnen mit direkten oralen Antikoagulantien (DOAK) nimmt seit ihrer Zulassung stetig zu. Das Risiko für traumatische Hirnblutungen sowie für einen schwerwiegenden Verlauf nach einem Schädel-Hirn-Trauma (SHT) ist für diese PatientInnen kaum erforscht. Anerkannte internationale Richtlinien für das Management von Schädel-Hirn-Trauma PatientInnen beruhen weitestgehend auf Literatur zu älterer antithrombotischer Therapie (ATT). Es ist unklar, wie sich der Verlauf eines SHT bei Einnahme von DOAK von anderer ATT unterscheidet. Methoden: 1200 PatientInnen mit SHT und Schädel CT bei Aufnahme wurden in diese retrospektive Fall-Kontroll-Studie eingeschlossen. 473 PatientInnen unter laufender DOAK Therapie (Rivaroxaban, Edoxaban, Apixaban oder Dabigatran) wurden in unsere Fallgruppe aufgenommen. 727 PatientInnen unter ATT mit Marcoumar, Acetylsalicylsäure (ASS), Clopidogrel oder Enoxaparin mit SHT wurden in die Kontrollgruppe eingeschlossen. Unterschiede hinsichtlich Inzidenz für Hirnblutungen, Mortalität und weiteren Outcome Parametern wurden deskriptiv sowie mittels statistischer Tests für unterschiedliche Medikamentenklassen analysiert. Ergebnisse: In unserer Studie zeigte sich eine niedrigere Inzidenz intrakranieller Blutungen bei PatientInnen mit DOAK (6.98%) im Vergleich zur Kontrollgruppe mit anderer ATT (10.73%), jedoch ohne statistischer Signifikanz (p=0.369). Innerhalb der Kontrollgruppe zeigte sich die niedrigste Inzidenz intrakranieller Blutungen bei PatientInnen mit Marcoumar, (5.22%) während bei Einnahme von Plättchenhemmern 13.19% der PatientInnen eine Blutung aufwiesen. Es zeigte sich ein signifikanter Unterschied in der Inzidenz primärer Blutungen im Vergleich von DOAK und Plättchenhemmern (6.98% vs. 13.19%, p=0,001). Bei insgesamt 6 PatientInnen (0,5%) kam es im Verlauf des Aufenthalts zum Auftreten von sekundären Hirnblutungen ohne signifikanten Unterschieden zwischen den Medikamentenklassen. Es konnten keine signifikanten Unterschiede hinsichtlich der Mortalität oder der Krankenhausaufenthaltsdauer festgestellt werden. Schlussfolgerung: PatientInnen mit DOAK haben ein vergleichbares Risiko für traumatische Hirnblutungen wie PatientInnen mit anderer ATT. PatientInnen unter Therapie mit DOAK haben eine signifikant niedrigere Inzidenz traumatischer Hirnblutungen im Vergleich zu PatientInnen unter Plättchenhemmern.Introduction The number of patients treated with direct oral anticoagulation (DOAC) is rapidly increasing since its regulatory approval. The risk for traumatic intracranial hemorrhage (tICH) and the possibility of severe negative outcomes after traumatic brain injury (TBI) are insufficiently explored. International guidelines for the management of traumatic brain injury are based mostly on the research of older antithrombotic therapies. The effects of DOAC compared to other antithrombotic therapy (ATT) in patients with TBI are unclear. Methods We included 1200 patients with TBI who underwent cranial CT at admission in this retrospective case-control study. 473 TBI patients with DOAC therapy (Rivaroxaban, Edoxaban, Apixaban or Dabigatran) could be enclosed. 727 TBI patients with Marcoumar, acetylsalicylic acid (ASA), Clopidogrel or Enoxaparin could be included in the control-group. The differences in incidence of tICH, mortality and other outcome parameters were descriptively analyzed and statistically tested for different groups of medication. Results Our study shows a lower incidence of tICH in patients with DOAC (6.98%) compared to our control-group (10.73%), without statistical significance (p=0.369). The lowest incidence of intracranial hemorrhage was measured in patients with Marcoumar (5.22%). The highest incidence was reported in the group of antiplatelet therapy (13.19%). Patients with DOAC had a significantly lower incidence of tICH than patients with antiplatelet agents (6.98% vs. 13.19%, p=0.001). 6 patients (0.5%) developed a delayed intracranial hemorrhage during the observation period with no significant difference between medication groups. There were no significant differences in mortality or length of stay. Conclusion Patients with DOAC have a similar risk for traumatic intracranial hemorrhage as patients with other antithrombotic therapy. Patients with DOAC therapy have a significant lower incidence for tICH compared to patients with antiplatelet agents.Abweichender Titel laut Übersetzung der Verfasserin/des VerfassersArbeit an der Bibliothek noch nicht eingelangt - Daten nicht geprüftMedizinische Universität Wien, Diplomarb., 2019(VLID)361630

Management of Traumatic Brain Injury in Patients with DOAC Therapy–Are the “New” Oral Anticoagulants Really Safer?

(1) Background: In recent years, “new” direct oral anticoagulants (DOAC) have gradually replaced other antithrombotic therapies. The international literature agrees on the increased mortality for traumatic brain injury (TBI) patients using vitamin K antagonists (VKA), but thus far, there are insufficient data on the influence of DOAC on the outcome of TBI. (2) Methods: We retrospectively analyzed data from all patients who presented with head trauma using antithrombotic therapy. Outcome parameters were the presence of pathologies on the initial CT, occurrence of delayed intracranial hemorrhage, surgical intervention, and death. (3) Results: In total, data of 1169 patients were reviewed. Of those, 1084 (92.7%) had a mild TBI, 67 (5.7%) moderate TBI, and 17 (1.5%) severe TBI. In total, 456 patients (39%) used DOAC and 713 patients (61%) used VKA, antiplatelet therapy, or prophylactic doses of low molecular weight heparin at the time of trauma. The groups showed no significant differences in age, injury mechanisms, or GCS at presentation. Overall, the initial cranial CT showed pathologies in 85 patients (7.3%). Twenty-five patients with head trauma and DOAC therapy had pathological findings on CT (5.5%), 11 patients with VKA (4.8%), and 48 patients with antiplatelet therapy (10.6%). There was a statistically significant difference in occurrence of CT pathologies between DOAC alone compared to acetylsalicylic acid (4.9 vs. 10.5%, p = 0.04). Delayed intracranial hemorrhage after an initially negative CT during in-hospital observation occurred in one patient (0.2%) in the DOAC group, two patients (0.9%) in the VKA group, and four patients (0.9%) in the antiplatelet group without statistical significance. Head trauma related surgery was performed in three patients (0.7%) in the DOAC group, two patients (0.9%) in the VKA group, and six patients (1.3%) in the antiplatelet group without statistical significance. Death due to head trauma occurred in four patients (0.9%) of the DOAC group compared to one patient (0.4%) of the VKA group and five patients (1.1%) of the antiplatelet group without statistical significance. (4) Conclusions: Our data suggest a comparable risk of pathological CT findings, delayed intracranial hemorrhage, surgical interventions, and death after blunt head trauma for patients with DOAC compared to VKA, but a lower risk for pathological CT findings compared to platelet inhibitors. As VKA are known to increase mortality, our data suggest that similar caution should be used when treating patients with head trauma and DOAC, but the overall numbers of serious or severe courses after simple falls remain low. We recommend routine CT for all head trauma patients with antithrombotic therapy but the role of in-hospital observation for patients with mild TBI remains a matter of debate