Traumatic brain injury in patients with mechanical heart valves on lifelong anticoagulation: incidence, management, and outcomes of intracranial hemorrhage.

OBJECTIVES: Patients with mechanical heart valves require lifelong anticoagulation, exposing them to a substantially elevated risk of hemorrhagic complications following traumatic injury. Traumatic brain injury (TBI) in this population represents a particularly challenging clinical dilemma, as the coexistence of intracranial hemorrhage and the obligatory need for anticoagulation places competing physiologic imperatives in direct conflict. Despite the clinical relevance of this scenario, data on the incidence, management, and outcomes of TBI in anticoagulated mechanical valve patients remain scarce. This study aimed to characterize the incidence and severity of TBI and intracranial hemorrhage in this population, to evaluate the impact of hemorrhage on composite good outcome, and to compare outcomes between surgical and conservative management strategies. METHODS: We conducted a retrospective observational cohort study of patients with mechanical heart valves who sustained at least one traumatic event at the University Hospital Zurich during 2012 and 2023. The primary outcome was a composite good outcome at one month, defined as absence of neurological sequelae, no new bleeding, and no progression of intracranial hemorrhage. Anticoagulation reversal strategies were recorded for all patients. Admission INR values were extracted from emergency laboratory records where available. RESULTS: Among 60 patients with mechanical heart valves, 43 (71.7%) sustained at least one TBI, yielding 50 TBI events over the study period. The majority of TBIs were mild (90%), with a median patient age at first TBI of 73 years (interquartile range 56.5-79.8). Intracranial hemorrhage was present in 30 of 50 TBIs (60%). A composite good outcome was achieved in 18 of 20 TBIs (90%) without intracranial hemorrhage, compared with 20 of 30 TBIs (66.7%) with intracranial hemorrhage. Among hemorrhagic TBIs, good outcome was observed in 5 of 9 surgically managed cases (55.6%) and 15 of 21 conservatively managed cases (71.4%). CONCLUSIONS: Intracranial hemorrhage following TBI is common in anticoagulated mechanical valve patients and is associated with a lower rate of composite good outcome compared to TBI without hemorrhage (66.7% vs. 90.0%). Among haemorrhagic TBI events, composite good outcomes were numerically more frequent with conservative than with surgical management (71.4% vs. 55.6%); however, given the small number of surgical cases (n = 9), probable selection toward more severe haemorrhages in the surgical group, and the study's absence of statistical power to detect a clinically meaningful difference (p = 0.43), this comparison must be regarded as exploratory and hypothesis-generating only. No conclusions regarding the comparative effectiveness of conservative vs. surgical management can be drawn from this cohort. Admission INR data were available for 94% of TBI events (47 of 50). Median admission INR was 2.2 [IQR 1.6-3.1] overall; haemorrhagic TBI events had a significantly lower median admission INR than non-haemorrhagic events (1.8 [IQR 1.4-2.6] vs. 3.0 [IQR 1.9-3.3]; p = 0.025), suggesting that injury biomechanics rather than anticoagulation intensity alone determines haemorrhagic risk. These findings underscore the need for prospective multicentre data and standardised management protocols in this high-risk population.