Routine Repeat Head CT may not be Indicated in Patients on Anticoagulant/Antiplatelet Therapy Following Mild Traumatic Brain Injury

Abstract

IntroductionEvaluation recommendations for patients on anticoagulant and antiplatelet (ACAP) therapy that present after mild traumatic brain injury (TBI) are controversial. At our institution, an initial noncontrast head computed tomography (HCT) is performed, with a subsequent HCT performed six hours later to exclude delayed intracranial hemorrhage (ICH). This study was performed to evaluate the yield and advisability of this approach.MethodsWe performed a retrospective review of subjects undergoing evaluation for ICH after mild TBI in patients on ACAP therapy between January of 2012 and April of 2013. We assessed for the frequency of ICH on both the initial noncontrast HCT and on the routine six-hour follow-up HCT. Additionally, chart review was performed to evaluate the clinical implications of ICH, when present, and to interrogate whether pertinent clinical and laboratory data may predict the presence of ICH prior to imaging. We used multivariate generalized linear models to assess whether presenting Glasgow Coma Score (GCS), loss of consciousness (LOC), neurological or physical examination findings, international normalized ratio, prothrombin time, partial thromboplastin time, platelet count, or specific ACAP regimen predicted ICH.Results144 patients satisfied inclusion criteria. Ten patients demonstrated initial HCT positive for ICH, with only one demonstrating delayed ICH on the six-hour follow-up HCT. This patient was discharged without any intervention required or functional impairment. Presenting GCS deviation (p<0.001), LOC (p=0.04), neurological examination findings (p<0.001), clopidogrel (p=0.003), aspirin (p=0.03) or combination regimen (p=0.004) use were more commonly seen in patients with ICH.ConclusionRoutine six-hour follow-up HCT is likely not indicated in patients on ACAP therapy, as our study suggests clinically significant delayed ICH does not occur. Additionally, presenting GCS deviation, LOC, neurological examination findings, clopidogrel, aspirin or combination regimen use may predict ICH, and, in the absence of these findings, HCT may potentially be forgone altogether.

Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy

“…The results of our study, with only one clinically significant case of delayed intracranial hemorrhage (0.3% in the repeat CT group, 0.1% in total), support other investigations which concluded that a routine repeat CT is not necessary for patients with antithrombotic therapy, due to the low clinical significance of most detected DIH [27,28,29,30,31,32]. The single case of a clinically significant DIH in our study showed an altered neurological status and would therefore have received an additional CT during the observation period regardless of clinical protocol for routine repeat CT.…”

Delayed intracranial hemorrhage in elderly anticoagulated patients sustaining a minor fall

“…Most of these analyses have considered limited panels of ACAP medications and have not addressed patients taking multiple ACAP medications. Even in cases where a DICH is detected, neurosurgical operative intervention has been shown to be infrequent [ 17 , 19 , 20 ].…”

Delayed Intracranial Hemorrhage in Patients Taking Warfarin with Head Trauma

“…It has been well documented in the literature that being on Warfarin therapy does present genuine immediate increased risk of intracranial bleed in patients with head injuries. 6,7 Some studies suggest as many as 17% of such patients can present with an intracranial bleed 2,6,8 and American College of Emergency Physicians guidelines recommend an immediate initial head CT. 7 Reviews of the literature on delayed bleed rates, however, reveal that this phenomenon is inconsistently tracked or studied. 5,7,9,10 In fact, the results of previous studies have suggested that bleeds of this type may occur days to weeks after initial injury.…”