Reappraising the need for a control CT in mild head injury patients on anticoagulation

Abstract

Background Head injury is a frequent reason for admission to the emergency department. In parallel, there is a growing use of anticoagulants in an increasingly aging population, which renders this particular group of trauma patients more frequent. In several countries, including Portugal, a 24-h surveillance period followed by repetition of head computed tomography (CT) is the standard procedure for these patients. However, these recommendations have not been based on studies of prevalence of intracranial hemorrhages in control head CTs, namely in this group of anticoagulated patients. This study intends to evaluate the prevalence of de novo intracranial hemorrhages in control head CTs in anticoagulated patients. Method An observational study was carried out, which included patients admitted to Hospital de Braga between June 2017 and January 2018, victims of head injury and on anticoagulation therapy, whose admission head CT excluded intracranial hemorrhage. Results We collected a total of 201 patients, with a mean age of 81.6 years, and 57.5% of them were prescribed warfarin; 181 of these patients repeated the head CT 24 h later. Of these 181 patients, 3 (1.66%) exhibited intracranial hemorrhage in control CT, without surgical indication. All patients were followed up 1 month after the trauma, and there was no readmission requiring hospitalization, surgery or death. Conclusions In conclusion, de novo intracranial hemorrhage in control head CT of anticoagulated patients is rare. We propose that these patients may be discharged if the admission CT does not reveal intracranial hemorrhage, providing that they are accompanied by a caregiver and informed about red flags.

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

“…The increase in the ICH rate as the INR increases is in line with the findings of previous reports [ 42 , 43 , 44 , 45 ]. However, the figure has not been confirmed by all studies [ 46 ]. It should be noted that 18% of our population had subtherapeutic INR values; according to previous studies, a value of 1.5 is considered subtherapeutic [ 47 ].…”

“…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 ].…”

“…A study showed that the hemorrhages on the control CT scan were only seen under warfarin and this further suggests that this drug might be more frequently associated with delayed bleeding than DOACs [ 46 ]. However, we agree with the authors that studies evaluating the impact of DOACs in these patients are practically non-existent, and further research is needed in this area.…”

“…It is essential to provide each MHI patient with an information sheet on what to do at home and to ensure that there is a caregiver present [ 41 , 51 , 70 ]. 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 ].…”