Peck Kimberly A, Sise C Beth, Shackford Steven R, Sise Michael J, Calvo Richard Y, Sack Daniel I, Walker Sarah B, Schechter Mark S
Trauma Service, Scripps Mercy Hospital, San Diego, California 92103, USA.
J Trauma. 2011 Dec;71(6):1600-4. doi: 10.1097/TA.0b013e31823b9ce1.
Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero.
We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1.
Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma.
The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.
创伤中心越来越频繁地评估在受伤时正在接受抗凝或处方抗血小板（ACAP）治疗的患者。由于有报道称该患者群体在钝性创伤后会出现延迟性颅内出血（ICH），我们对入院时接受ACAP治疗并进行头部计算机断层扫描（CT）（CT1），随后在6小时内进行常规重复头部CT（CT2）的患者进行了评估。我们假设在CT1上没有创伤性发现且神经学检查正常或无变化的患者中，具有临床意义的延迟性ICH的发生率为零。
我们回顾性分析了2006年1月至2009年8月入住我们一级创伤中心的成年钝性创伤患者，这些患者在受伤前接受ACAP治疗。我们回顾了药物治疗、损伤机制、头部CT结果和预后情况。记录了人口统计学数据、损伤严重程度评分、国际标准化比值和神经学检查结果。我们确定了CT1为阴性的患者在CT2上延迟性ICH的发生率。
500名患者符合该方案。其中，424名患者（85%）CT1为阴性。在这些患者中，平均年龄为75岁；210名（50%）为男性。跌倒为最常见的损伤机制，在357名患者（84%）中发现。单独服用华法林的患者占68%，单独服用氯吡格雷的患者占24%，服用其他药物的患者占2%。6%的患者同时服用两种药物。服用华法林患者的平均国际标准化比值为2.5。在CT1为阴性的患者中，362名患者（85%）进行了CT2检查，其中358名患者（99%）CT2为阴性。4名（1%）CT1为阴性的患者CT2为阳性（n = 3）或可疑阳性（n = 1）。CT2上所有的变化都很轻微，在第三次头部CT时已消退或稳定。在CT2为阳性或可疑阳性的4名患者中，神经学检查均无变化；然而，有两名患者有可归因于头部损伤的症状。3名患者出院回家，1名患者死于与头部创伤无关的心脏病。
我们研究中延迟性ICH的发生率为1%。然而，所有延迟性发现均无临床意义。在ACAP治疗且CT1为阴性、神经学检查正常或无变化的患者中，常规CT2检查不必要。我们建议进行一段时间的观察，以识别那些可能因延迟性ICH而出现症状的患者。
