| Objective:To analyze the clinical course and imaging features of patients with long-term oral anticoagulant and antiplatelet medications(ACAP)combined with traumatic brain injury(TBI),and to explore the acute neurological function,acute imaging deterioration and short-term prognosis of ACAP in patients with TBI.Methods:A total of 1211 consecutive TBI patients were retrospectively enrolled from the First Affiliated Hospital of Soochow University,from January 01,2014 to December 31,2018.Excluding patients who did not meet the criteria,a total of 346 patients with TBI were enrolled,and clinical and imaging data were collected.All patients were divided into the medication group and non-medication group according to whether the long-term use of ACAP before the injury,the medication group included anti-platelet group and anti-coagulation group.The antiplatelet group was further divided into three subgroups:aspirin only(AO)group,clopidogrel only(CO)group,and aspirin+clopidogrel(AC)group;the anticoagulation group was further divided into two subgroups:warfarin only(WO)group and new oral anticoagulant(NOAC)group.The CT scan of the head of all patients on admission was reviewed to assess the amount of bleeding,the type of injury and the midline structure displacement,whether the basal pool was compressed or disappeared,and to dynamically observe the expansion of the hematoma during hospitalization.The amount of bleeding was calculated using the ABC/2 method.Hematoma enlargement was defined as a relative increase in hematoma volume>33%or/and an absolute increase of>6 ml on the first CT scan after admission and CT reexamination within 72 h.Acute neurological deterioration was defined as:GCS score decreased by≥2 points,one side loss of pupillary light reflex,pupil diameter irregularities>2 mm,focal motor dysfunction or occurrence of cerebral hernia.Acute imaging deterioration was defined as hematoma enlargement or Rotterdam CT score increased by≥1 point.T-test and Mann-Thitney U rank-sum test were used to compare the demographic and clinical characteristics of patients at admission,and to further compare clinical and imaging outcomes(including hematoma enlargement,acute imaging deterioration,acute neurological deterioration,neurosurgical intervention,total hospital length of stay,ICU length of stay and mechanical ventilation time)and short-term prognosis(30-day mortality).Finally,a multivariate binary logistic regression model was used to investigate the effects of ACAP on acute neurological function and acute imaging deterioration and short-term prognosis.Results:(1)This study included 346 patients with simple moderate to severe TBI who were>50 years old,including 84 patients(24.3%)in the medication group,including 58 patients(16.8%)in the antiplatelet group and 26 patients(7.5%)in the anticoagulation group.In each subgroup,32 patients in the AO group,15 in the CO group,11 in the AC group,18 in the WO group,and 8 in the NOAC group;262 in the non-medicated group.(2)In the injury mechanism,the proportion of traffic accidents in the medication group decreased significantly compared with the non-medication group(28.6%vs 49.2%,P<0.001).and the proportion of ground falls increased significantly(27.4%vs 15.3%,P=0.015).The rise of the ground falls in the anticoagulation group(38.5%)was the primary cause.(3)Among the injury types,the incidence of mixed hematoma and intraventricular hematoma in the medication group was significantly higher than that in the non-medicated group(29.8%vs 16.8%,P=0.012 and 19.0%vs 7.6%,P=0.006),while epidural hematomas were Significantly lower than the non-medicated group(13.1%vs 28.2%,P=0.005).(4)The overall 30-day mortality rate was 21.1%in this group,which was significantly higher in the medication group than in the non-medication group(33.3%vs 17.2%,P=0.003).(5)Compared with the non-medicated group,the incidence of acute neurological deterioration and acute imaging deterioration was higher in the medication group(38.1%vs 24.4%,P=0.018 and 35.7%vs 22.5%,P=0.021).The proportion of neurosurgery interventions was greater(52.4%vs 37.4%,P=0.004),with longer ICU length of stay and mechanical ventilation time(P=0.033 and P=0.035)compared with the medication group.(6)AO,CO,AC,and NOAC did not significantly increase the risk of acute neurological deterioration in patients(P>0.05),while the risk of acute neurological deterioration in the WO group was 3.02 times that of the non-medicated group.Warfarin is an independent risk factor for acute neurological deterioration(OR 3.02,95%CI 1.10-8.32,P=0.032).Age,hypertension,initial bleeding volume ≤10 ml,and head AIS score at admission were independent risk factors for acute neurological deterioration(P<0.05).(7)AO,AC,and NOAC did not significantly increase the risk of acute imaging deterioration in patients(P>0.05),while the risk of acute imaging deterioration in the CO and WO groups was 3.42 and 3.16 times that of the non-medicated group,respectively.Clopidogrel and warfarin were independent risk factors for acute imaging deterioration(OR 3.42,95%CI 1.03-11.36,P=0.045 and OR 3.16,95%CI 1.11-8.99,P=0.031).Age,hypertension,subdural hematoma,mixed hematoma,initial bleeding volume ≤10 ml,and head AIS at admission were independent risk factors for acute imaging deterioration(P<0.05).(8)AO,CO,AC,and NOAC did not significantly increase the risk of 30-day death in patients(P>0.05),while the risk of 30-day death in the WO group was 3.57 times that in the untreated group.The risk of 30-day death in the WO group was 3.57 times that of the untreated group,and warfarin was an independent risk factor for 30-day mortality(OR 3.57,95%CI 1.11-11.55,P=0.033).Hypertension,head AIS at admission,mixed hematoma,acute neurological deterioration,and acute imaging deterioration were independent risk factors for 30-day mortality(P<0.05).(9)The AUC of the multivariate binary logistic regression model for acute neurological deterioration,acute imaging deterioration,and 30-day mortality in this study was 0.6919,0.7424 and 0.8112,respectively,indicating that the model established in this study was reasonable.Conclusion:(1)The proportion of traffic accidents in patients with moderate to severe TBI who took ACAP before the injury was significantly decreased,and the proportion of ground falls increased significantly;(2)Antiplatelet drugs or NOAC did not significantly increase the acute neurological deterioration of patients with TBI and the risk of 30-day of death;(3)Aspirin,aspirin+clopidogrel or NOAC did not significantly increase the risk of acute imaging deterioration in patients with TBI;however,clopidogrel alone was an independent risk factor for acute imaging deterioration.(4)Warfarin is an independent risk factor for acute neurological and acute imaging deterioration and 30-day mortality in patients with TBI.(5)Hypertension,head AIS at admission,mixed hematoma,acute neurological deterioration,and acute imaging deterioration are independent risk factors for 30-day mortality in TBI patients. |
