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The increasing incidence of traumatic brain injury (TBI) in older adults—many of whom are prescribed direct oral anticoagulants (DOACs)—highlights the critical need to determine safe strategies for restarting anticoagulation after such injuries.
Early initiation or resumption of apixaban appears safe in carefully selected traumatic brain injury patients following a stable head CT, with no signs of hemorrhage progression or need for urgent neurosurgical intervention.
The increasing incidence of traumatic brain injury (TBI) in older adults—many of whom are prescribed direct oral anticoagulants (DOACs)—highlights the critical need to determine safe strategies for restarting anticoagulation after such injuries. DOAC therapy is associated with higher risks of bleeding and mortality post-TBI. This retrospective analysis examined apixaban usage following acute TBI, aiming to address the current lack of clear guidelines and data regarding anticoagulation in this vulnerable group.
Eligible subjects (n=10; median age of 72 ± 10.5 years) were aged 18 or older, had a TBI with an Abbreviated Injury Score (AIS-Head) of ≥2, a positive head computed tomography (CT) scan, and had apixaban either started or resumed during their hospital stay. Head CT scans were evaluated at 4 intervals: initial scan, stability scan, pre-apixaban scan, and final follow-up.
Median Glasgow Coma Scale (GCS) score and AIS-Head score were 14 ± 1 and 3 ± 1, respectively. Apixaban was commenced a median of 9 ± 6 days after the first stable CT scan. Follow-up imaging occurred a median of 35.5 ± 19.5 days after initiating apixaban. None of the patients experienced novel or progressive intracranial bleeding or required unplanned neurosurgical procedures after starting apixaban. Notably, 2 patients died due to medical complications from their trauma, unrelated to anticoagulation therapy.
Initiating or restarting apixaban at an earlier stage appeared to be a safe approach for carefully chosen TBI patients, provided their head CT scan shows stability and there is no immediate requisition for invasive neurosurgical intervention. More research is needed to substantiate these outcomes and better define the most suitable timing for apixaban use after TBI.
World Neurosurgery: X
Safety of anticoagulation with apixaban following acute traumatic brain injury: A case series
Abhishek R. Mogili et al.
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