Utility of INR For Prediction of Delayed Intracranial Hemorrhage Among Warfarin Users with Head Injury |
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| Institution: | 1. Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Michigan;2. Department of Internal Medicine, St. Mary Mercy Hospital, Livonia, Michigan;3. Department of Emergency Medicine, Broward Health Medical Center, Fort Lauderdale, Florida;4. Department of Trauma Surgery, St. Mary Mercy Hospital, Livonia, Michigan;6. Department of Emergency Medicine, Sparrow Hospital, Michigan State University, Lansing, Michigan;5. Bluefield College-Via College of Osteopathic Medicine, Blacksburg, Virginia;7. Department of Radiology, St. Mary Mercy Hospital, Livonia, Michigan;1. Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan;2. Walter Reed National Military Medical Center, Bethesda, Maryland;1. Division of Emergency Medicine, Department of Medicine, Western University, London, Ontario, Canada;2. Alberta Health Services, Calgary, Alberta, Canada;3. Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada;4. Schwartz/Reisman Emergency Medicine Institute, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada;6. Southwest Ontario Regional Base Hospital Program, London Health Sciences Centre, London, Ontario, Canada;1. Department of Emergency Medicine, Jacobi and Montefiore Hospitals, Albert Einstein College of Medicine, Bronx, New York;2. Department of Pediatrics at Jacobi Hospital, Albert Einstein College of Medicine, Bronx, New York |
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| Abstract: | BackgroundIncidence of delayed intracranial hemorrhage (DICH) in patients on warfarin has been controversial. No previous literature has reported the utility of international normalized ratio (INR) in predicting traumatic DICH.ObjectivesUtilizing INR to risk stratify head trauma patients who may be managed without repeat imaging.MethodsThis was a retrospective study at a Level II trauma center. All patients on warfarin with head injuries from March 2014 to December 31, 2017 were included. Each patient underwent an initial head computed tomography scan (HCT) and subsequent repeat HCT 12 h after. Patients presenting > 12 h after head injury received only one HCT. Two blinded neuroradiologists reviewed each case of DICH. Statistical analysis evaluated Glasgow Coma Scale (GCS), Injury Severity Score (ISS), heart rate, systolic blood pressure (SBP), age, and platelet count.ResultsThere were 395 patients who qualified for the protocol; 238 were female. Average age was 79 years. Seventy-seven percent of patients underwent repeat HCT. Five resulted in DICH (INR 2.6–3.0), three of which might have been present on initial HCT; incidence rate of 0.51–1.27%. One patient required neurosurgical intervention. Among 80 patients with INR < 2, no DICH was identified, resulting in high sensitivity, but with a wide confidence interval; sensitivity of 100% (95% confidence interval CI] 47.8–100), specificity 21% (95% CI 16.6–28.9). Correlation of factors: ISS (p = 0.039), GCS (p = 0.978), HR (p = 0.601), SBP (p = 0.198), age (p = 0.014), and platelets (p = 0.281).ConclusionNo patient with INR < 2 suffered DICH, suggesting that warfarin users presenting with INR < 2 may be managed without repeat HCT. For INR > 2, patients age and injury severity can be used for shared decision-making to discharge home with standard head injury precautions and no repeat HCT. |
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| Keywords: | anticoagulated delayed intracranial hemorrhage head injury trauma warfarin |
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