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Comment & Response
May 2015

Risks and Benefits of Resumption of Anticoagulation Following Traumatic Brain Injury Remain Complex and Uncertain—Reply

Author Affiliations
  • 1University of Maryland School of Medicine, Baltimore
  • 2Philips Healthcare, San Francisco, California
  • 3IMPAQ International, LLC, Columbia, Maryland
JAMA Intern Med. 2015;175(5):866-867. doi:10.1001/jamainternmed.2015.0301

In Reply We appreciate the opportunity to respond to the comments of Grandhi and coauthors regarding our study examining the risks and benefits of warfarin therapy resumption following traumatic brain injury (TBI) in anticoagulated older adults.1

Grandhi et al note that “inclusion of patients with skull fractures and concussions without evidence of intracranial hemorrhage skewed the sample population because these individuals have no risk of re-hemorrhage…” following resumption of anticoagulation therapy. Cohen et al2 observed that anticoagulated patients with Glasgow Coma Scale scores of 13 to 15 (those with mild TBI or concussion) and normal initial computed tomographic scans were at risk of clinical deterioration and subsequent development of new hemorrhages. Furthermore, current guidelines for the management of mild TBI call for 24-hour observation of anticoagulated patients with normal initial computed tomographic scans.3 Given that 75% of TBIs are mild, these 2 facts seem to support our inclusion of concussion cases and suggest that mild TBI cases represent the majority of anticoagulated adults hospitalized with TBI.4 Despite this, only 55% of patients in our study resumed warfarin therapy for at least 1 month following hospital discharge.

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