• Charlie J Nederpelt, Stefano J M van der Aalst, Martin G Rosenthal, Pieta Krijnen, Menno V Huisman, Wilco C Peul, and Inger B Schipper.
• From the Department of Trauma, Emergency Surgery and Surgical Critical Care (C.N., M.G.R.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Trauma Surgery (C.J.N., S.J.M.v.d.A., P.K., I.B.S.), Department of Thrombosis and Hemostasis (M.V.H.), and Department of Neurosurgery (W.C.P.), Leiden University Medical Center, Leiden University, Leiden, The Netherlands.
• J Trauma Acute Care Surg. 2020 Jan 1; 88 (1): 186-194.

BackgroundThe rapid adoption and widespread use of direct oral anticoagulants (DOACs) has outpaced research efforts to establish their effects in bleeding trauma patients. In patients with complicated traumatic brain injury (TBI) caused by intracranial hemorrhage, DOAC use may be associated with higher bleeding volume and potentially more disastrous sequelae than use of vitamin K antagonists (VKAs). In the current systematic review and meta-analysis we set out to evaluate the literature on the relationship between preinjury DOAC use and course of the intracranial hemorrhage. (ICH), its treatment and mortality rates in TBI patients, and to compare these outcomes to those of patients with preinjury VKA use.MethodsPubMed, Embase, Web of Science, and the Cochrane Library were searched using a search strategy including three main terms: "traumatic brain injury," "direct oral anticoagulants," and "vitamin K antagonists." There were 1,446 abstracts screened, and ultimately, six included articles. Random effects modeling meta-analysis was performed on in-hospital mortality, ICH progression and neurosurgical intervention rate.ResultsAll cohorts had similar baseline and emergency department parameters. Within individual studies surgery rate, reversal agents used, ICH progression and in-hospital mortality differed significantly between DOAC and VKA cohorts. Meta-analysis showed no significant difference in in-hospital mortality (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.23-4.06; I = 76%; p = 0.97), neurosurgical interventions (OR, 0.48; 95% CI, 0.14-1.63; p = 0.24), or ICH progression rates (OR, 1.86; 95% CI, 0.32-10.66; p = 0.49) between patients that used preinjury DOACs versus patients that used VKAs.ConclusionDirect oral anticoagulant-using mild TBI patients do not appear to be at an increased risk of in-hospital mortality, nor of increased ICH progression or surgery rates, compared with those taking VKAs.Level Of EvidenceSystematic review, level III.

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