Fallsrepresenttheleadingcauseoftraumaticbraininjuryinadultsolderthan65,withnearlyonethirdexperiencingafalleachyear1.Evidencesuggeststhatup to 0.5% of anticoagulated patients suffer from ICH annually3. AlthoughDOACs have become an increasingly popular alternative to warfarin foranticoagulation,researchregardingtheirsafety,speciIicallyontheoutcomesoftraumatic ICH is sparse. Moreover, the literature presents conIlicting datacomparing outcomes of patients on DOACs or warfarin with ICH.1,2 Severalretrospectivestudiesanda fewmeta-analyseshaveexaminedthe incidenceofICH and DOAC use,3-7 but only a few directly compare the outcomes of ICHcoincidentwithDOACorwarfarinuse.3-6Furthermore,thesestudiesaremostlycohorttrials,containinglimitedsamplesofICHpatients;manyofthesearticlescontain fewer than ten ICH patients, andmost do not consider traumatic ICHseparately.2-7 This study is a retrospective review, considering outcomes oftraumatic ICH in DOAC patients, querying Saint Francis Hospital’s TraumaQuality Improvement Program (TQIP) database to bring to light anyassociations between DOAC use (as compared with warfarin) and mortality,operative intervention, hospital and intensive care unit lengths of stay (HLOSand ICU LOS respectively), transfusion requirements, and discharge to skillednursingfacility(SNF).

Compared with warfarin, direct oral anticoagulants are associated with improved patient outcomes in blunt traumatic ICH

Acknowledgments Theauthors,MonicaDiFiori,LillaKis,andDr.JamesFeeneywouldliketothankDr.VijayJayaramanandDr. StephanieMontgomery of Saint Francis Hospital—Trinity Health New England’s Surgery ServiceLine for their contributions, as well as Elizabeth Santone of University of Connecticut School ofMedicine. The authorswould also like to thank Dr. Sarah Raskin of Trinity College’s Department ofPsychologyandNeuroscienceProgramforherguidanceandsupport.

Monica DiFiori ‘16, Lilla Kis ‘18, James Feeney, MD, FACS Trinity College and Saint Francis Hospital—Trinity Health New England, Surgery Service Line, Hartford CT

References 1. Centers for Disease Control and Prevention: home and Recreational Safety: Data & Statistics Website

http://www.cdc.gov/HomelanfdRecreationalSafety/Falls?adultfalls.html. Accessed February 19, 2016.

2. Alonso A, Bengtson LG, MacLehose RF, Lutsey PL, Chen LY, Lakshminarayan K. Intracranial hemorrhage mortality in atrial fibrillation patients treated with dabigatran or warfarin. Stroke. 2014;45(8):2286-91.

3. Hagii J, Tomita H, Metoki N, Saito S, Shiroto H, Hitomi H, Kamada T, Seino S, Takahashi K, Baba Y, Sasaki S, Uchizawa T, Iwata M, Matsumoto S, Osanai T, Yasujima M, Okumura K. Characteristics of intracerebral hemorrhage during rivaroxaban treatment: comparison with those during warfarin. Stroke. 2014;45(9):2805-7.

For a complete list of references, contact Monica DiFiori (monica.difiori@trincoll.edu) or Lilla Kis (Lilla.kis@trincoll.edu).

INTRODUCTION

METHODS

RESULTS

(SD= Standard Deviation, ISS= Injury Severity Score, GCS= Glasgow Coma Score, AIS= Abbreviated Injury Score, MOI= Mechanism of Injury, MVC= Motor Vehicle Crash, CI= Confidence Interval)

Table1:PatientCharacteristics,DOACsvs.WarfarininTraumaticICH

CONCLUSIONS

Table2:PrimaryandSecondaryOutcomes,DOACsvs.WarfarininTraumaticICH

•  Comparedwithwarfarin,DOACsareassociatedwith:•  Improvedmortality•  Decreaseinprogressiontooperativeintervention•  DecreasedrateofSNFdischarge

•  Comparedwithwarfarin,DOACswerenotassociatedwithadifferentICULOSnorHLOS

•  Furtherdirections:•  AlthoughthisstudyhasthelargestsamplesizeoftraumaticICHassociatedwithDOACusetodate,alarge,multicentertrialwouldresultinamorecomprehensivepatientcohort

•  RandomizedcontrolledtrialtobettercomparetheeffectsofwarfarinandDOACs,eliminatinganypossiblecorrelationbetweeninsuranceorsocioeconomicstatusandDOACuseandpatientoutcomes

(SD= Standard Deviation, ICU LOS= Intensive Care Unit Length of Stay, HLOS= Hospital Length of Stay, SNF= Skilled Nursing Facility, CI= Confidence Interval)

OBJECTIVE

The purpose of this study was to elucidate the effects of direct oralanticoagulants (DOACs) in comparison to warfarin in anticoagulated patientssustainingtraumaticintracranialhemorrhage(ICH).

Patientswhopresentedtothehospital

from6/1/2011-9/1/2015withICHwhentaking

anticoagulantswerepulledfromtheTQIP

registryanonymously.

PatientswerestratiIiedbasedon

prescriptionofDOACsorwarfarin.

Patientdemographics,includingage,gender,GlasgowComaScore(GCS)onarrival,AbbreviatedInjuryScore(head)(AIS

(head)),MechanismofInjury(MOI)and

InjurySeverityScore(ISS)werecomparedbetweenthetwo

groups.Students-ttestwasusedtocomparemeanageandISS.

Fisher'sexacttestwasusedtocompare

genderandMOI.MannWhitneyU-testwasusedtocompareGCSonadmissionandAIS

(head).

Patientoutcomesincludingmortality,needforoperativeintervention,HLOS,ICULOS,proportion

ofpatientstransfusedanddischargetoSNF

werethencomparedbetweenthetwo

groups.Fisher'sexacttestwasusedto

comparemortality,needforoperativeinterventionandSNFdischarge.Mann

WhitneyU-testwasusedtocomparemedianHLOSand

ICULOS.

Fisher’sexacttestwasusedtocompareinjury

characteristics,suchastype,locationandnumberoflesions.

DirectOralAnticoagulants Warfarin (p)

Age(years)±SD 77.2±11.2 79.5±13 0.25

Gender(M/F)±SD

54.7%Male(95%CI44.9%to69.0%)

60.3%Male(95%CI50.6%to69.4%) 0.74

MeanISS±SD 16.4±8.1 18.2±8.7 0.19

MeanAdmissionGCS±SD

14±1.3 13±2.6 0.12

MedianAIS(Head)±SD 3.25±1.2 3.5±1.2 0.07

MOI:Falls 93.4%(95%CI83.9%to97.9%)

95.0%(95%CI88.7%to98.2%) 1.0

MOI:MVC 6.6%(95%CI2.1%to16.1%)

3.0%(95%CI0.7%to8.7%) 0.43

MOI:Assault 0.0%(95%CI0%to7.1%)

2.0%(95%CI0.1%to7.4%) 0.53

DirectOralAnticoagulants Warfarin (p)

MedianICULOS(days)±SD 1.4±0.27 1.2±9.2 0.87

MedianHLOS(days)±SD 4±3.5 4±6.9 1.0

ProportionofPatients

Transfused±SD

14.8%(95%CI7.73%to26.0%)

21.8%(95%CI14.8%to30.9%) 0.31

NumberofUnitsperPatient

Transfused±SD9patients/18units±0.88 22patients/88Units±4.45 0.54

ProportiondischargedtoSNF

±SD

28.8%(95%CI3.2%to18.2%)

39.7%(95%CI18.8%to41.5%) 0.03

OperativeIntervention

8.2%(95%CI3.2%to18.2%)

26.7%(95%CI19%to36.1%) 0.02

Mortality 4.9%(95%CI1.1%to14.0%)

20.8%(95%CI15.6%to31.9%) 0.008

Onehundredsixty-twopatientsmetinclusioncriteria,61intheDOACgroupand101inthewarfarin group. DOAC usewas associatedwith highermortality (DOAC group 4.9% versuswarfarin group20.8%;p<0.008), a lower rate of operative intervention (DOACgroup8.2%versuswarfaringroup26.7%;p=0.02),andalowerobservedrateofdischargetoSNF(DOACgroup28.8%versuswarfaringroup39.7%;p=0.03)(seetable2).

DirectOralAnticoagulants Warfarin (p)

SDH(%) 54.1%(95%CI41.7%to66.0%)

54.5%(95%CI44.8%to63.8%) 1.0

SAH(%) 41.0%(95%CI29.5%to53.5%)

27.7%(95%CI19.9%to37.2%) 0.09

IPH(%) 29.5%(95%CI19.5%to42.0%)

27.7%(95%CI19.9%to37.2%) 0.86

IVH(%) 13.1%(95%CI7.5%to21.0%)

12.9%(95%CI6/5%to24.1%) 1.0

Onelesion(%)

72.1%(95%CI59.8%to81.9%)

74.3%(95%CI64.9%to81.8%) 0.86

Twolesions(%)

18.0%(95%CI10.2%to29.7%)

22.8%(95%CI15.6%to31.9%) 0.55

Threeormorelesions(%)

9.8%(95%CI4.3%to20.2%)

3.0%(95%CI0.7%to8.7%) 0.08

Table3:InjuryCharacteristics,DOACsvs.WarfarininTraumaticICH

(SDH= Subdural Hematoma, SAH= Subarachnoid Hemorrhage, IPH= Intraparenchymal Hemorrhage, IVH= Intraventricular Hemorrhage, CI= Confidence Interval)