title: AHEAD Study: an observational study of the management of anticoagulated patients who suffer head injury.
abstract: Management of anticoagulated patients after head injury is unclear due to lack of robust evidence. This study aimed to determine the adverse outcome rate in these patients and identify risk factors associated with poor outcome.
  
  
  
  Multicentre, observational study using routine patient records.
  
  
  
  33 emergency departments in England and Scotland.
  
  
  
  3566 adults (aged ≥16 years) who had suffered blunt head injury and were currently taking warfarin.
  
  
  
  Primary outcome measure was rate of adverse outcome defined as death or neurosurgery following initial injury, clinically significant CT scan finding or reattendance with related complication within 10 weeks of initial hospital attendance. Secondary objectives included identifying risk factors for adverse outcome using univariable and multivariable analyses.
  
  
  
  Clinical data available for 3534/3566 patients (99.1%), median age 79 years; mean initial international normalised ratio (INR) 2.67 (SD 1.34); 81.2% Glasgow Coma Scale (GCS) 15: 59.8% received a CT scan with significant head injury-related finding in 5.4% (n=208); 0.5% underwent neurosurgery; 1.2% patients suffered a head injury-related death. Overall adverse outcome rate was 5.9% (95% CI 5.2% to 6.7%). Patients with GCS=15 and no associated symptoms had lowest risk of adverse outcome (risk 2.7%; 95% CI 2.1 to 3.6). Patients with GCS=15 multivariable analysis (using imputation) found risk of adverse outcome to increase when reporting at least one associated symptom: vomiting (relative risk (RR) 1.8; 95% CI 1.0 to 3.4), amnesia (RR 3.5; 95% CI 2.1 to 5.7), headache (RR 1.3; 95% CI 0.8 to 2.2), loss of consciousness (RR 1.75; 95% CI 1.0 to 3.0). INR measurement did not predict adverse outcome in patients with GCS=15 (RR 1.1; 95% CI 1.0 to 1.2).
  
  
  
  In alert warfarinised patients following head injury, the presence of symptoms is associated with greater risk of adverse outcome. Those with GCS=15 and no symptoms are a substantial group and have a low risk of adverse outcome.
  
  
  
  NCT02461498.
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mason
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Maxine
authors.initials: M
authors.lastname: Kuczawski
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: M Dawn
authors.initials: MD
authors.lastname: Teare
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Matt
authors.initials: M
authors.lastname: Stevenson
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Goodacre
authors.affiliation: Emergency Department, Northern General Hospital, Sheffield, UK.
authors.forename: Shammi
authors.initials: S
authors.lastname: Ramlakhan
authors.affiliation: Emergency Department, Northern General Hospital, Sheffield, UK.
authors.forename: Francis
authors.initials: F
authors.lastname: Morris
authors.affiliation: School of Health and Related Research, University of Sheffield, Sheffield, UK.
authors.forename: Joanne
authors.initials: J
authors.lastname: Rothwell
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000647:Amnesia / Q000453:epidemiology; D000925:Anticoagulants / Q000009:adverse effects*; D000070642:Brain Injuries, Traumatic / Q000000981:diagnostic imaging* / Q000401:mortality; D004636:Emergency Service, Hospital; D005260:Female; D015600:Glasgow Coma Scale; D016489:Head Injuries, Closed / Q000000981:diagnostic imaging* / Q000401:mortality; D006261:Headache / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D014057:Tomography, X-Ray Computed; D014474:Unconsciousness / Q000453:epidemiology; D014839:Vomiting / Q000453:epidemiology; D014859:Warfarin / Q000009:adverse effects*; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: Warfarin