Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis
Bibliographic record
Abstract
INTRODUCTION: Delayed intracranial hemorrhage (ICH) after a negative initial head cat scan (CT) is a recognized complication after blunt trauma but the risk of this condition is unknown. Due to theoretical increased risk in patients on direct oral anticoagulants (DOACs) and inability to monitor degree of anticoagulation, there is a lack of consensus regarding need for additional observation or routine repeat head CT. We hypothesized that patients on DOACs would have a low risk of delayed ICH after blunt head trauma. METHODS: In June 2020, an electronic literature search of MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library was performed by a medical librarian (TH) using a combination of keywords and subject headings. Databases were searched from inception through June 2020. Included studies reported outcome data on trauma patients greater than 18 years old who were taking anticoagulants and were observed after initial normal head CT. A meta-analysis was performed using a random effects model. The Newcastle-Ottawa Scale (NOS) was utilized for assessing the quality of nonrandomized studies in meta-analyses. RESULTS: Our electronic search returned 5719 papers and after removal of duplications, 72 underwent full review, and 12 met final inclusion/exclusion criteria. Four thousand eight hundred ninety one of 5289 (92%) patients suffered a ground level fall. Four studies reported routine repeat CT scans on all patients while the remaining only repeated CT scans for symptoms. Overall, 5289 patients were studied and 1263 (23.9%) were on a DOAC. Sixty-nine patients suffered delayed intracranial hemorrhage, 25 on DOAC and 44 on warfarin. The pooled weighted proportion for delayed ICH on DOAC was 2.43% (95% CI, 1.31 – 3.88%) compared to 2.31% (95% CI, 1.26 – 3.66%) on warfarin. Eighty six percent of patients (59/69) who suffered delayed ICH had no clinical consequences while 0.16% (2/1263) of those on DOAC and 0.48% (8/1788) of those on warfarin died from complications following delayed ICH. The overall crude risk of death from delayed ICH while on DOAC or Warfarin was 0.36% (11/3051). CONCLUSIONS: The risk of delayed ICH following low energy blunt head trauma for patients on DOACs is low, and the risk of a clinically significant bleed is even lower. The practice of routinely observing or systematically repeating head CT in patients on DOACs after low energy blunt head trauma with initially negative head CT may not be warranted.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.009 | 0.025 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.016 | 0.026 |
| Bibliometrics | 0.007 | 0.009 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.003 | 0.001 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.002 | 0.001 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".