Evaluation of the yield of 24-h close observation in patients with mild traumatic brain injury on anticoagulation therapy: a retrospective multicenter study and meta-analysis

Abstract

Delayed (diagnosis of) ICH within 24 h is very rare in mTBI patients on anticoagulants after reportedly normal initial CT. Routine hospitalization of these patients seems unwarranted when the initial cranial CT is scrupulously evaluated.

Rates of Intracranial Hemorrhage in Mild Head Trauma Patients Presenting to Emergency Department and Their Management: A Comparison of Direct Oral Anticoagulant Drugs with Vitamin K Antagonists

“…In adults, observation has been shown to be as effective as the CT in the presence of a caregiver and a patient able to understand home instructions [ 46 ]. Our results show similar percentages of positive second CTs of the brain as previous studies [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ]. In addition, even our patients who tested positive for the second CTs did not require surgery, as another study showed.…”

“…In our observation, the rate of delayed hemorrhage was relatively low. We, therefore, with some prudence, align with other authors that suggest that patients presenting with a negative first CT scan and without neurological deterioration can be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ]. We also think that this could apply especially to patients on DOAC.…”

“…Patient management for those on VKAs and DOAC does not differ, and the observation period is 24 h. This involves resource utilization and a longer stay in ED, as demonstrated by the long LOS ( Table 3 ). However, the need for a control head CT scan in patients on anticoagulation therapy that do not display neurological deterioration is disputable, since the incidence of late ICH is between 0 and 7% [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ]. Some countries, such as Italy, have guidelines stating that all anticoagulated patients who have undergone a head CT should be observed for 24 h and have a repeat CT before discharge; others suggest discharge only after observation or observation in the community.…”

“…Despite specialist emergency care, mortality is reportedly high, with up to 34% dying in hospitals [ 49 , 67 , 68 , 69 ]. The problem of LOS is well recorded in the literature, and some authors have proposed that patients on anticoagulant therapy may be discharged if the admission CT does not reveal an ICH, provided that they are accompanied by a caregiver and are informed about red flags [ 20 , 43 , 46 , 59 , 62 , 63 , 64 , 65 , 66 ].…”

Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta‐analysis of prospective studies

“…This is the first meta‐analysis to address this question. Two recent meta‐analyses reported a very low rate of delayed ICH in anticoagulated head injured patients with a normal head CT scan (Chauny et al , ; Verschoof et al , ). These meta‐analyses did not report on the incidence of ICH at evaluation in the ED.…”