Do We Need Delayed Head CT for Anticoagulated TBI Patients

Written by John Korducki

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Patients ≥65 years on warfarin with head injury were found to have a significantly higher rate of delayed intracranial hemorrhage (dICH) compared to patients on direct oral anticoagulants (DOACs) and those not on anticoagulation.

Why does this matter?
Elderly falls are a common presenting complaint to the emergency department, with these patients having higher rates of anticoagulation. Hospital policies may dictate practice patterns, such as observation or re-scanning at a later time, so it’s important to know how to treat, risk stratify, and advise these patients.

WAR(farin)… what is it good for?
This was a large (69,321 patients!) retrospective cohort study that demonstrated a higher rate of dICH among elderly patients on warfarin (1.8%) compared to those on DOACs (1.0%) or no anticoagulation (1.0%). The methods defined dICH as any intracranial hemorrhage recorded within 90 days of index ED visit for head trauma in a large patient database within the province of Ontario – which is a fair amount of time from index visit compared to other studies. Also, they did not define head injury or stratify based on mechanism or injury severity. Nonetheless, what I take away from these data are that the overall risk of dICH is low, even in elderly patients on warfarin. As we will cover tomorrow, I think that a clinician should consider the mechanism, concurrent injuries, and co-morbidities when considering when to re-scan or hold a patient for observation and be slightly more cautious in those on warfarin, particularly those with a supratherapeutic INR. However, a large majority of these patients can be discharged after initial imaging with good coaching and return precautions.

Source
Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department. CJEM. 2022 Oct 15. doi: 10.1007/s43678-022-00392-z. Epub ahead of print.