Are Repeat Head CT Scans Indicated in Anticoagulated Patients With Minor Head Injuries Following Initial Negative Head CT?
Date First Published:
September 30, 2014
Last Updated:
September 30, 2014
Report by:
S. Cham Sante, Medical Student (The Commonwealth Medical College)
Three-Part Question:
In [anticoagulated patients with minor head injury and initial negative head CT scan] does a [repeat head CT scan] improve [clinical outcome]?
Clinical Scenario:
An 80 year old man with a history of atrial fibrillation on warfarin presents to the emergency department after a ground level fall. He reports hitting his head, but denies loss of consciousness. Vital signs are stable and within normal limits at presentation, GSC is 14. Physical exam is unremarkable. Initial head CT scan is read as negative for acute abnormality without evidence of intracranial hemorrhage. Can the patient safely be discharged home?
Search Strategy:
PubMed: [Head CT] and [Trauma or Head Injury] and [Anticoagulation or Anticoagulant] limit to English language, humans
Outcome:
Altogether 133 papers were found, 6 were relevant to the clinical question and of sufficient quality for inclusion. Details of the five most relevant papers are found in Table 1.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. Kaen A, Jimenez-Roldan L, Arrese I, Delgado MA, Lopez PG, Alday R, Alen JF, Lagares A, Lobato RD. 2010 Spain | -137 adult patients on preinjury anticoagulation with minor head injury and normal initial head CT scan. All patients underwent 24 hours of observation and a repeat head CT scan prior to discharge. -Patients with traumatic intracranial hemorrhage on initial CT scan were excluded |
Prospective, observational study | #NAME? | - 2 of 137 patients demonstrated intracranial hemorrhage on repeat head CT scan (1.4%) - 0 of 137 patients demonstrated neurological deterioration or required neurosurgical intervention - The 2 patients with intracranial hemorrhage on repeat head CT were 2 of 3 patients in the study on both anticoagulant and antiplatelet therapy. | -Observational study -Potential for selection bias -Small sample size |
| Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulation and prescription antiplatelet agents at risk? Peck KA, Sise BC, Shackford SR, Sise MJ, Calvo RY, Sack DI, Walker SB, Schechter MS. 2011 USA | - 424 adult blunt trauma patients receiving anticoagulant or prescription antiplatelet therapy with a normal initial head CT scan. -Patients with traumatic intracranial hemorrhage on initial CT scan were excluded |
Retrospective review | -Presence of intracranial hemorrhage on repeat head CT scan 6hrs following initial negative head CT -Neurological deterioration -Readmission rates | - 4 of 362 patients who received repeat head CT scan demonstrated intracranial hemorrhage (1%) -None of these were found to be clinically significant - 3 of 4 were discharged home, 1 died of unrelated cause | Repeat head CT scan not obtained in 15% of patients with an initial negative head CT scan. |
| Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. 2012 Italy | - 87 patients >14yrs with minor head injury, defined as a head injury and a presenting Glascow Coma Scale (GCS) score of 14 or 15 regardless of presence of LOC. Patients had to present to ED within 48 hrs of injury and be on oral anticoagulants (Warfarin) for at least 1 week. -Patients with traumatic intracranial hemorrhage on initial CT scan were excluded. |
Prospective case series | - 4 of 5 patients with positive repeat head CT had INR >3 but study was not powered to determine statistical significance of predictors of intracranial hemorrhage -Small sample size -Case series level IV evidence -Potential for selection bias |
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| Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF 2012 USA | - 1,064 adult patients with blunt head trauma and preinjury warfarin or clopidogrel use within 7 days of injury, regardless of LOC. -687 of these patients were on preinjury warfarin -Patients with traumatic intracranial hemorrhage on initial CT scan were excluded |
Prospective, observational, multicenter | #NAME? | -Delayed traumatic intracranial hemorrhage was identified in 4 of 687 patients on preinjury warfarin (0.6%) and 0 of the 243 patients on preinjury clopidogrel (0%) | -Observational study -Potential for selection bias -Due to ethical considerations, definitive repeat head CT scans were not obtained on all patients |
| Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan:education instead of hospitalizati Schoonman GG, Bakker DP, Jellema K. 2014 The Netherlands | - 211 adult patients on preinjury oral anticoagulation with minor traumatic brain injury (GSC 13-15) and LOC <60min with a normal initial head CT scan. Pt must have been on oral anticoagulant for >1 week with an INR >1.1 -Patients with traumatic intracranial hemorrhage on initial CT scan were excluded |
Retrospective review | #NAME? | - 5 of 211 patients were found to have intracranial hemorrhage on repeat head CT, but in retrospect only 2 of these patients had initially negative head CT scans -Therefore, only 2 of 211 patients developed intracranial hemorrhage after initial negative head CT scan (.09%) -Intracranial hemorrhage in both of these patients occurred >19 days after injury | -Misinterpretation of 3 initial head CT scans incorrectly inflated number of new intracranial hemorrhages found on repeat head CT scan. |
Bottom Line:
Repeat head CT scans are not indicated in anticoagulated patients with minor head injuries following initial negative head CT scan. Randomized controlled trials are needed to establish evidence-based decision rules for this patient population.
References:
- Kaen A, Jimenez-Roldan L, Arrese I, Delgado MA, Lopez PG, Alday R, Alen JF, Lagares A, Lobato RD.. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury.
- Peck KA, Sise BC, Shackford SR, Sise MJ, Calvo RY, Sack DI, Walker SB, Schechter MS.. Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulation and prescription antiplatelet agents at risk?
- Menditto VG, Lucci M, Polonara S, Pomponio G, Gabrielli A. . Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol.
- Nishijima DK, Offerman SR, Ballard DW, Vinson DR, Chettipally UK, Rauchwerger AS, Reed ME, Holmes JF. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use.
- Schoonman GG, Bakker DP, Jellema K. . Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan:education instead of hospitalizati