Impact of Antithrombotic Agents on Radiological Lesion Progression in Acute Traumatic Brain Injury: A CENTER-TBI Propensity-Matched Cohort Analysis.

Abstract

An increasing number of elderly patients are being affected by TBI and a significant proportion are on pre-hospital antithrombotic therapy for cardio- or cerebrovascular indications. We have quantified the impact of antiplatelet/anticoagulant (APAC) agents on radiological lesion progression in acute TBI, using a novel, semi-automated approach to volumetric lesion measurement, and explored the impact of use on clinical outcomes in the CENTER-TBI study. We used a 1:1 propensity-matched cohort design, matching controls to APAC users based on demographics, baseline clinical status, pre-injury comorbidities and injury severity. Subjects were selected from a pool of patients enrolled in CENTER-TBI with computed tomography (CT) scan at admission and repeated within 7d of injury. We calculated absolute changes in volume of intraparenchymal, extra-axial, intraventricular and total intracranial hemorrhage between scans, and compared volume of hemorrhagic progression, proportion of patients with significant degree of progression (>25% of initial volume), proportion with new intracranial hemorrhage on follow-up CT as well as clinical course and outcomes. A total of 316 patients were included (158 APAC users; 158 controls). The mean volume of progression was significantly higher in the APAC group for extra-axial (3.1 vs 1.3 mL, p=0.01), but not intraparenchymal (3.8 vs 4.6 mL, p=0.65), intraventricular (0.2 vs 0.0 mL, p=0.79) or total intracranial hemorrhage (7.0 vs 6.0 mL, p=0.08). More patients had significant hemorrhage growth (54.1 vs 37.0%, p=0.003) and delayed intracranial hemorrhage (4 of 18 vs none; p=0.04) in the APAC group compared to controls, but this was not associated with differences in length of stay, rates of neurosurgical intervention, mortality or GOSE at 6 months. Preinjury use of antithrombotic agents was associated with greater expansion of extra-axial lesions, higher rates of significant hemorrhagic progression and higher risk of delayed traumatic intracranial hemorrhage, but this was not associated with worse clinical course or functional outcomes.