Three Part Question
In [adults with head injury] does [pre-injury aspirin] adversely [affect clinical outcome]?
A 65 year old man on aspirin presents to the emergency department having fallen sustaining a minor head injury. You wonder whether he is at higher risk of intracranial bleeding due to aspirin.
Medline using the OVID interface 1966- August Week 4 2005 Embase 1980–2005 week 37
The Cochrane Library Issue 3 2005
Medline: [exp brain injuries/ OR brain injur$.mp. OR exp craniocerebral trauma/ OR head injur$.mp.] AND [exp aspirin/ OR aspirin.mp. OR exp acetylsalicylic acid/ OR antithromb$.mp.] Limit to humans and English
Embase: [craniocerebral trauma.mp. OR exp Head Injury/ OR exp Brain Injury/ OR brain injur$.mp] AND [aspirin.mp. or exp Acetylsalicylic Acid/ OR antithrom$.mp] LIMIT to Human, English Language and (adult <18 to 64 years> or aged <65+ years>)
The Cochrane Library: Exp Aspirin [MeSH] AND exp brain injuries [MeSH] OR exp craniocerebral trauma [MeSH]
Altogether 103 were found in Medline and 104 in Embase. Three were relevant to the three part question, these are shown in the table below:
|Author, date and country
||Study type (level of evidence)
|Reymond MA et al,|
|189 patients with severe head injury||Retrospective Risk analysis||Chronic subdural haematoma||Aspirin is a risk factor for chronic subdural haematoma||Retrospective nature of the study|
|Mina AA et al,|
|37 patients admitted with intracranial injury on anticoagulants 37 case matched patients||Retrospective case controlled||Mortality due to head injury||Higher percentage of those on aspirin than any other anticoagulant died||Retrospective, Subgroup analysis, and small sample size|
|Spektor S et al,|
|Mild (GCS13-15) and moderate (GCS 9-12) head injuries in 231 patients >60 years old. 110 of which were on aspirin therapy||Prospective cohort study||Intracranial haemorrhage||No difference in frequency or type of ICH whether on aspirin or not||Small sample size.
Mild & moderate injuries included|
There was conflicting evidence that prior chronic use of aspirin increases the risk of intracranial haemorrhage following minor head injury. However, there is some evidence to suggest that there is increased risk of chronic subdural haemorrhage. A well designed prospective cohort study with adequate sample size and follow up is needed to address such important and common problem.
Clinical Bottom Line
Pre-injury aspirin may increase the risk of intracranial complications following head injury. More research is needed.
- Reymond MA. Marbet G. Radu EW. Gratzl O. Aspirin as a risk factor for haemorrhage in patients with head injuries. Neurosurg Rev 15(1):1992;21-25.
- Mina AA. Knipfer JF. Park DY. Bair HA et al. Intracranial complications of preinjury anticoagulation in trauma patients with head injury. J Trauma 53(4):2002;668-672.
- Spektor S. Agus S. Merkin V. Constantini S. Low –dose aspirin prophylaxis and risk of intracranial hemorrhage in patients older than 60 years of age with mild or moderate head injury: a prospective study. J Neurosurg 99(4):2003;661-665.