Minor Head Injury and Anticoagulants

Guidelines advise performing imaging in those patients on anticoagulants who have suffered minor head injury. We virtually all dutifully obey, because, even though the incidence of intracranial hemorrhage is low – it’s still much higher than zero. But, how high, really? Particularly when they’re sitting there, looking normal, with a GCS of 15?

This systematic review and meta-analysis gathered together 5 studies comprising 4,080 anticoagulated patients with GCS 15 following a head injury. Three of the studies mandated imaging, while the others allowed physician discretion with observation, telephone, and chart-review follow-up to ascertain outcomes. The vast majority of patients were on Vitamin K antagonists, and most mechanisms of injury – where documented – were falls.

Overall, there were 209 (5%) patients with ICH after their fall, nearly all of which were diagnosed at the index visit. There was a wide range of findings, ranging from 4% in the largest studies to 22% in the smaller. However, the larger studies were the ones with the least-complete follow-up after the index event. Therefore, these authors’ random effects analysis and sensitivity analysis generated higher estimates of the incidence, up to 10.9%.

So, while yield is low, we’re still far from having a strategy to support selective scanning to improve value. While it is unlikely many of these would have neurosurgical intervention indicated, a substantial portion likely underwent anticoagulation reversal to prevent further morbidity or mortality. While resource stewardship is always an important consideration, it is unlikely we will anytime soon be altering our approach to minor head injury in the context of anticoagulation.

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

https://www.ncbi.nlm.nih.gov/pubmed/30028001

4 thoughts on “Minor Head Injury and Anticoagulants”

  1. What’s your take on observation after head injury on noac/doac if initial head ct is negative. Do you repeat ct after 6-8 hours or 24 hours? The guidelines do not guide one way or another as they are still relatively new to the market. Great review!

    1. I virtually never observe/repeat CT. I wouldn’t say it never happens, but it’s so infrequent I can’t justify subjecting everyone to observation. I don’t really have a feeling regarding when I might – a nebulous combination of how high the INR might be, some context of the mechanism, and/or lack of responsible parties to watch patient at home.

      NOACs ought to be lower-risk, in general, unless there is reason to believe they’ve been taken inappropriately or there’s another reason for elevated levels (e.g., renal failure in dabigatran).

  2. Even more hand wringing over the definition of “minor head injury.” Does just any knock on the noggin count?

    1. In this convenience sample, they were effectively selected by the sheer fact they underwent CT. So, no, no precise definition.

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