Utility of Thromboelastography in Detecting NOAC-Related Coagulopathy in Traumatic Brain Injury

Novel oral anticoagulants (NOACs) have gained popularity as a vitamin K antagonist alternative without regular monitoring. There has been an increase in elderly patients on NOACs admitted for traumatic brain injury (TBI). The aim of this study is to determine the efficacy of thromboelastography (TEG) in detecting NOAC-related coagulopathy among TBI patients.

A retrospective chart review of 456 TBI patients admitted to Sentara Norfolk General Hospital from 2015 to 2020 was performed. Inclusion criteria comprised patients on NOACs with a TEG performed at presentation (66 patients). Analysis included TEG values, use of prothrombin complex concentrate factor 4 (PCC4), increased intracranial hemorrhage on repeat head computed tomography within 24 h of admission, and mortality.

TEG results showed 0% elevated reaction time, 1.5% elevated kinetics time, 1.5% low alpha angle, 4.5% low max amplitude, and 3.0% elevated clot lysis percent at 30 min in our cohort. Despite overwhelmingly normal TEG results, 42.42% of patients received PCC4. A subset analysis of these patients compared to those who did not receive PCC4, revealed a higher frequency of increased intracranial hemorrhage on repeat head computed tomography within 24 h of admission (42.86% versus 18.42%, P = 0.03), and increased mortality (25.0% versus 5.26%, P = 0.0219). Patients who did not receive PCC4 had no increased frequency of operative intervention or worsening of Glasgow Coma Score.

Results suggest that TEG does not reliably assess NOAC-related coagulopathy in TBI patients. Caution must be used when interpreting TEG data to determine reversal strategies in TBI patients on NOACs.