Aims/Objectives/Background Patients taking anticoagulant medication frequently attend the Emergency Department following head injuries. Whilst previously these patients were taking warfarin, they are now increasingly taking DOACs. Both classes of anticoagulant are believed to increase the incidence of traumatic intracranial haemorrhage (tICH). However, it is unclear whether DOACs confer the same risks as warfarin. There are also concerns that anticoagulated patients, who have had an initially normal CT scan, are at risk of delayed tICH.

This systematic review and meta-analysis compares the incidence of early and delayed tICH in patients attending the Emergency Department on DOACs and warfarin.

Methods/Design A literature search was conducted using the Medline(OVID and PubMed), EMBASE, Web of Science and Cochrane libraries using defined keywords. Prospective studies and retrospective studies were included. The primary outcomes were the incidences of early and delayed tICH. Mortality rates were also assessed. Meta-analyses were performed to compare the rates of early and delayed tICH between the anticoagulant groups. The rates of injury were also compared to patients not receiving anticoagulation.

Results/Conclusions The literature search found 42 relevant studies. Twenty three studies investigated the incidence of early tICH and 26 assessed delayed tICH. The pooled incidence of early tICH was 5.7% for DOACs and 7.3% for warfarin. Odds ratio for early tICH on DOACs was 0.47% (95% CI 0.34–0.66) when compared to warfarin and 0.96 (95%CI 0.68–1.36) compared to no anticoagulation. The incidence of delayed tICH was 1.2% for DOACs and 1.8% for warfarin (OR 0.70 (95% CI 0.38–1.31)). Odds ratio of mortality following a head injury on DOACs compared to warfarin was 0.4 (95%CI 0.17–0.94).

The systematic review and meta-analysis suggests the rate of early tICH and mortality may be lower for patients on DOACs as compared to warfarin. It also finds that the rate of delayed tICH bleeding is low in both groups.