Delayed Traumatic ICH and Oral Anticoagulants

Washington University Emergency Medicine Journal Club – May 19th, 2022


You are working a moonlighting shift at a local level II trauma center when you meet Mr. X, a 68-year-old gentleman with a history of atrial fibrillation, for which he takes diltiazem for rate control and apixaban for anticoagulation. This morning, while walking his dog, a rare crossbreed known as a great yorkie (a cross between a great Dane and a Yorkshire terrier), he was tripped up by the leash and fell forward, striking his forehead on the concrete. He suffered no loss of consciousness, has a mild headache, and has had no nausea or vomiting. His wife states that he has had no altered mental status since the fall. 

On exam he has a GCS of 15, a superficial abrasion to his forehead with a small 4 cm hematoma, no cervical spine pain or tenderness, and a normal neurologic examination. Being an astute reader of the literature, you remember that the studies on the Canadian Head CT rules excluded patients on anticoagulation, and proceed to order a head CT, which is read as normal by the attending radiologist (not a neuroradiologist). 

After updating the patient’s tetanus booster you discharge him home in the care of his wife. That night after your shift, you begin to worry about your patient and his risk of delayed intracranial hemorrhage given his anticoagulant use. You are aware of a prior journal club that found a low risk of delayed bleed with warfarin use, but you wonder if the results apply to patients taking Xa inhibitors and direct thrombin inhibitors. Unable to sleep, you head online and begin to search the literature for answers. 

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Article 1: Cohan CM, Beattie G, Bowman JA, Galante JM, Kwok AM, Dirks RC, Kornblith LZ, Plevin R, Browder TD, Victorino GP. Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study. J Trauma Acute Care Surg. 2020 Aug;89(2):301-310. doi: 10.1097/TA.0000000000002760. PMID: 32332255.

Article 2:Puzio TJ, Murphy PB, Kregel HR, Ellis RC, Holder T, Wandling MW, Wade CE, Kao LS, McNutt MK, Harvin JA. Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis. J Am Coll Surg. 2021 Jun;232(6):1007-1016.e5. doi: 10.1016/j.jamcollsurg.2021.02.016. Epub 2021 Mar 22. PMID: 33766725; PMCID: PMC8722268.

Article 3: Mourad M, Senay A, Kharbutli B. The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs). Injury. 2021 Sep;52(9):2571-2575. doi: 10.1016/j.injury.2021.05.039. Epub 2021 Jun 1. PMID: 34130854.

Article 4: Turcato G, Cipriano A, Zaboli A, Park N, Riccardi A, Santini M, Lerza R, Ricci G, Bonora A, Ghiadoni L. Risk of delayed intracranial haemorrhage after an initial negative CT in patients on DOACs with mild traumatic brain injury. Am J Emerg Med. 2022 Mar;53:185-189. doi: 10.1016/j.ajem.2022.01.018. Epub 2022 Jan 15. PMID: 35063890.

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