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Report by Dr Richard Parris, Consultant in Emergency Medicine
Search checked by Dr Zia Hassan, Registrar in Emergency Medicine, Hope Hospital
Royal Bolton Hospital
A short cut review was carried out to establish whether patients who are on clopidogrel and suffer a minor head injury have an increase in morbidity and/or mortality. Four papers had some data relevant to the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that there is insufficient evidence to state that clopidogrel worsens outcomes in patients with a minor head injury.
In a patient with a [head injury], does concurrent [treatment with clopidogrel] [increase morbidity and mortality]?
A 78‐year‐old male presents to the emergency department in a coma 2 days after a minor head injury. You note he is taking clopidogrel for treatment of his ischaemic heart disease. CT scan shows a large sub‐dural haematoma. You wonder whether the clopidogrel has contributed to the development of this haematoma?
Medline: 1950–2007 April week 1 [(brain injury.mp. or exp Brain Injuries/) OR (craniocerebral trauma.mp. or exp Craniocerebral Trauma/) OR (head injur$.mp.)] AND [(antithromb$.mp.exp Platelet Aggregation Inhibitors/or clopidogrel.mp.) OR (platelet aggregation inhibitor$.mp.)] limit to (humans and english language). EMBASE: [cranio‐cerebral trauma OR head injury] AND [clopidogrel OR antithrombocytic agent] LIMIT to humans
Medline yielded 113 papers, EMBASE 58. Four were relevant (table 33).
The clinical impression is that concomitant with the increase in the number of patients taking clopidogrel, there is a rise in the number of patients on clopidogrel presenting with significant intra‐cranial haemorrhage after minor head injury. Whether clopidogrel contributes to the development of the intra‐cranial haemorrhage is unclear and there is currently very little evidence addressing this subject. This is perhaps not surprising considering that clopidogrel is a relatively new drug and even with older established anticoagulant and anti‐thrombotic drugs such as warfarin and aspirin, there is continued debate about the quality and quantity of evidence delineating their exact role in the development of intra‐cranial haemorrhage following head injury.
There is insufficient evidence to firmly state that clopidogrel worsens outcomes in patients with minor head injury.