Patients who take antiplatelet or anticoagulant medications have a low risk of intracranial hemorrhage (ICH) associated with ground-level falls, researchers report.

“We found most surprising that anticoagulants did not have a higher rate of traumatic intracranial hemorrhage after a ground-level fall compared to antiplatelet agents such as aspirin,” Dr. Michael Ganetsky from Beth Israel Deaconess Medical Center, Harvard Medical School, in Boston, told Reuters Health by email. “This was somewhat counterintuitive since traditional teaching is to be most worried about people taking warfarin who fall and strike their head.”

Anticoagulants increase the risk and severity of traumatic ICH, even with minor head trauma, but few studies have compared the rate of traumatic ICH from antiplatelet and anticoagulant agents, including direct oral anticoagulants (DOACs).

Dr. Ganetsky’s team assessed the rates of ICH in emergency department patients on anticoagulants or antiplatelet agents who sustained a ground-level fall and received CT imaging in their prospective, observational cohort study of 939 patients (median age, 79.2 years). Overall, 33 patients (3.5%) showed CT evidence of a traumatic ICH, the team reports in Academic Emergency Medicine. More than a third (36 percent) were described as small, punctate, or tiny. Rates of traumatic ICH were 4.3 percent with antiplatelets and 1.7 percent with anticoagulants. Aspirin monotherapy had the highest point estimate rate of traumatic ICH (4.6 percent), whereas warfarin monotherapy had a rate of 2.1 percent. The rate of traumatic ICH when aspirin was used in combination with clopidogrel was 3.9 percent.

There were no traumatic ICHs in the DOAC group, but there were only 31 patients in that group.

Eight patients (0.9 percent) died within seven days and 30 (3.2 percent) died within 30 days of the initial emergency department visit. Only four of these 30 patients had a traumatic ICH identified on the initial CT.

“I don’t think these findings change the way we manage patients with head injury after a ground level fall,” Dr. Ganetsky said. “I don’t want people to take away that aspirin is more dangerous than anticoagulants since clinically significant intracranial hemorrhage (those requiring some form of intervention) was still very rare in our data set.”

“Our results are somewhat provocative and are adding to a growing body of knowledge but are still just from one center,” he added. “We think our methodology needs to be replicated across multiple centers both to confirm the similar rate that we observed and to enroll more patients taking newer direct oral anticoagulants to understand their bleeding propensity after head injury with ground-level fall.”

Dr. Michael W. Rich from Washington University School of Medicine in St. Louis, Missouri, told Reuters Health by email, “The main take-home message from this study—and I think it’s an important one—is that the risk of traumatic ICH in older patients experiencing a ground-level fall is low, regardless of whether they are taking antiplatelet agents or oral anticoagulants. Beyond that, I think it’s difficult to draw any firm conclusions about the relative risks with antiplatelet agents vs. oral anticoagulants because the number of traumatic ICHs was low (33), and only four of these patients were taking oral anticoagulants.”

“Although additional study of this important issue is needed, the current study supports the view that in most cases the occurrence of a fall or concern about high risk for falls should not be construed as a sufficient justification for avoiding antiplatelet or anticoagulant therapy when clinically indicated,” said Dr. Rich, who was not involved in the study.