Head injury while on anticoagulation

Abstract

reatment of mild traumatic brain injury (mTBI)/concussion is usually handled by emergency medicine and primary care physicians or the injured person might not seek medical care. When a patient is evaluated, imaging may not be not required if the neurologic examination is normal. However, if there are focal neurologic deficits, vomiting, headache, coagulopathy, age .60 years, outward evidence of head or neck trauma, intoxication, or a dangerous mechanism of trauma, then head CT or brain MRI is recommended. In situations where a patient has an initially negative head CT without any residual signs or symptoms, discharge from the emergency department (ED) is considered safe. However, this is not the case for patients on anticoagulation-immediate discharge from ED after a normal head CT may not be appropriate. 1 Traumatic brain injury (TBI) affects more than 1.7 million Americans yearly, and the proportion of Americans on anticoagulation is increasing (prescriptions at outpatient visits are up 38% from 2009 to 2014), so that more physicians are being faced with this dilemma without much literature to guide them. 2,3 Due to unknown rates of delayed intracranial hemorrhage (ICH), providers typically err on the side of caution and allow for a prolonged period of observation and obtain repeat head imaging. The utility of this practice is examined in this issue of Neurology ® Clinical Practice by Campiglio et al. 4 The authors retrospectively examine data in one center where the practice includes 48 hours of observation and a follow-up head CT. They found that among 284 patients on anticoagulation who had an initial CT that did not demonstrate hemorrhage, only 4 had hemorrhage on follow-up CT (1.4%), and not one of these was clinically significant. The article also points out that the cost for each hospitalization was approximately €654 in Europe and $8,152 in the United States. This study brings up the important point that it may not be financially prudent to observe all such patients and repeat scans. With a growing elderly population and a growing portion of them on anticoagulation, this is an extra expense our health care system could do without. It also informs clinical practice in that most patients on anticoagulation who have a fall from standing have a low likelihood of delayed ICH and lower likelihood of requiring neurosurgical intervention. The authors conclude that it is safe to discharge mTBI patients on anticoagulation after a negative head CT. This study does not fully address that question for the following reasons. The number of participants is limited and the population is homogenous, composed mostly of patients who had falls rather than motor vehicle accidents or other traumas. Rates of hemorrhage as high as 6% have been reported within a 24-hour observation window in a small See page 296

Post-stroke patients with moderate function have the greatest risk of falls: a National Cohort Study

“…The potential positive association between antithrombotic therapy (anticoagulation and antiplatelets) and falls likely arises from a bias in the detection of falls. Patients on antithrombotic therapy who fall are managed with greater caution due to greater risks of haemorrhage and are more likely to undergo brain scans and receive inpatient care [23, 24]. Also, these patients may be more likely to present for medical attention for falls due to precautions advised in case of trauma while on antithrombotic therapy.…”

Post-Stroke Patients with Moderate Function Have the Greatest Risk of Falls: A National Cohort Study

“…Two of these studies are well-powered and utilised cohort study designs (17,18), one of which used a large registry-based cohort with data on long-term outcomes (17). In contrast, most other studies demonstrate that worse disability and (23,24). Also, these patients may be more likely to present for medical attention for falls due to precautions advised in case of trauma while on antithrombotic therapy.…”

Acute and delayed intracranial hemorrhage in head-injured patients on warfarin versus direct oral anticoagulant therapy

“…Some experts argue that normal initial imaging of the head is not sufficient to rule out ICH due to concern that impaired hemostasis may result in delayed ICH. [ 13 ] Numerous clinical guidelines and trauma center policies share this concern and recommend that all anticoagulated patients who experience head trauma be admitted to the hospital for observation and routine repeat CT scan of the head. [ 14 15 16 17 ] For this reason, several studies have attempted to quantify the risk of delayed ICH in patients taking anticoagulants, antiplatelets, or both.…”