Safety of anticoagulation with apixaban following acute traumatic brain injury: A case series

The rise in traumatic brain injuries (TBI) among geriatric patients, often using direct oral anticoagulants (DOACs), underscores the urgency to explore safe resumption of these medications post-injury. DOAC use confers an increased risk of hemorrhage and mortality following TBI. This study focuses on the use of apixaban following acute TBI, addressing the paucity of data and guidelines on anticoagulation management in this population. A retrospective review of TBI patients admitted to NYC Health + Hospitals/Elmhurst, was conducted from April 2016 to December 2021. Inclusion criteria included age ≥18, a TBI with a head abbreviated injury score (AIS-Head) ≥2, a positive head computed tomography (CT) scan, and apixaban initiated or resumed after TBI. Head CT images were collected at four time points: initial, stability, pre-apixaban, and last follow-up. 10 patients were included. Median age was 72 ± 10.5 years, median Glasgow Coma Scale (GCS) score and AIS-Head scores were 14 ± 1 and 3 ± 1 respectively. Apixaban was initiated a median of 9 ± 6 days following the first stable head CT. The median radiological follow-up was 35.5 ± 19.5 days after starting apixaban. No patient had a new or worsening intracranial hemorrhage or unexpected need for neurosurgical intervention following initiation of apixaban. Two patients expired after prolonged hospitalizations from medical complications secondary to their trauma and unrelated to apixaban. Our results suggest that starting or resuming apixaban relatively early is likely safe in selected TBI patients following a stable head CT and with no anticipated imminent need for invasive neurosurgical procedures. Further studies are warranted to confirm these results and refine the optimal timing for initiating apixaban after TBI.