Computed tomography indications for mild traumatic brain injury in the anticoagulated patient

J.Sales-Llopis; J.A. Nieto-Navarro

Neurosurgery Service, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL - FISABIO Foundation), Alicante, Spain.

There are large variations in guideline adherence, especially in the situations considered ordering computed tomography for mild traumatic brain injury 1).

The presence of oral anticoagulant therapy alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI) 2) although it is still debated if patients with a Glasgow Coma Scale (GCS) score of 15 and normal findings on neurologic examination.

There are limited data available to characterize the risk of adverse outcomes in patients receiving direct oral anticoagulants after mild traumatic brain injury. A sufficiently powered prospective cohort study is required to validly define this risk, identify clinical features predictive of adverse outcomes, and inform future traumatic brain injury guidelines 3).

Colas et al. prospectively assessed head CTs performed in adults taking antiplatelet (AP)/anticoagulant (AC)/direct oral anticoagulant (DOAC)referred after an mild traumatic brain injury to the Emergency Departments between September 2016 and January 2018. The frequency, type, and severity of intracranial hemorrhages (IH) were described, and frequency was analyzed as a function of treatment.

840 patients were prospectively included. 58.9% were treated with AP, 23.7% with AC, 11.7% with DOAC, and 5.7% with a combination of antithrombotic agents. The rate of IH detected with head CT was 5.8% (n = 49), of which 81.6% (n = 40) and 18.4% (n = 9) with minor and intermediate severity respectively. No patient required surgical care and no death occurred. No statistically significant difference was found in treatment distribution between patients with or without IH (p = 0.98). Among the patients who discontinued their antithrombotic treatment after mTBI, three experienced thrombotic events during the hospitalization.

The results showed a low frequency and severity of IH in mTBI patients indifferently treated with AP, AC or DOAC, without secondary neurological deterioration, death, or need for surgical care. The study suggests the limited benefit of systematic CT head scans as a standard practice for the management of mTBI patients under antithrombotic therapy 4).

Covino et al. evaluated all consecutive patients admitted to our ED for MTBI, which had a control CT for late ICH after a negative CT at admission. We used a propensity score match (PSM) on factors affecting the need for oral anticoagulation to adjust the comparison between anticoagulated vs. non-anticoagulated patients for the baseline clinical characteristics.

Results: Among 685 patients enrolled, 15 (2.2%) developed ICH at control CT. After PSM, the incidence of ICH, although slightly higher, was not statistically different in anticoagulated patients vs. non-anticoagulated (2.3% vs. 0.6%, p=0.371). Among the 111 patients on VKA, 5 (4.5%) had a late ICH, compared to 4 out of 99 (4.0%) on DOACs; the difference was not statistically significant (p=0.868).

Conclusions: The risk of developing delayed ICH after MTBI in patients on anticoagulation therapy is low. After correction for baseline covariates, the risk does not appear higher compared to non-anticoagulated patients. Thus, a routine control CT scan seems advisable only for patients presenting a clinical deterioration. Larger, prospective trials are required to clarify the safety profile of DOACs vs. VKA in MTBI 5).

Retrospectively reviewed patients receiving heparin or coumadin who had head trauma and who subsequently underwent cranial CT at a level I trauma center within a 4-year period. Patients were evaluated for the mechanism of injury, clinical signs and symptoms of head injury, and type and reason for anticoagulation. Prothrombin time, international normalized ratio, partial thromboplastin time, GCS score, age, and head CT results were recorded for each patient.

A total of 89 patients fulfilled the enrollment criteria. Among them, 82 had no evidence of intracranial injury on CT. Seven patients had evidence of intracranial hemorrhage. Patients without hemorrhage had no significant focal neurologic deficits and presented with an average GCS score of 14.8. Patients with intracranial hemorrhage tended to have focal neurologic deficits and presented with an average GCS score of 12.0.

Patients with a head injury, normal GCS scores, and no focal neurologic deficits and who are receiving the anticoagulants heparin or coumadin may not necessarily require emergency CT 6).

Despite the higher theoretical risk of traumatic intracranial hemorrhage (ICH) in anticoagulated patients with a mild head injury, the value of sequential head CT scans to identify bleeding remains controversial.

De novo intracranial hemorrhage in control head CT of anticoagulated patients is rare. We propose that these patients may be discharged if the admission CT does not reveal intracranial hemorrhage, providing that they are accompanied by a caregiver and informed about red flags 7).

A study evaluated the utility of 2 sequential CT scans at a 48-hour interval (CT1 and CT2) in patients with mild head trauma (Glasgow Coma Scale 13-15) taking oral anticoagulants.

They retrospectively evaluated the clinical records of all patients on chronic anticoagulation treatment admitted to the emergency department for a mild head injury.

A total of 344 patients were included, and 337 (97.9%) had a negative CT1. CT2 was performed on 284 of the 337 patients with a negative CT1 and was positive in 4 patients (1.4%), but none of the patients developed concomitant neurologic worsening or required neurosurgery.

Systematic routine use of a second CT scan in mild head trauma in patients taking anticoagulants is expensive and clinically unnecessary 8).

Routine six-hour follow-up HCT is likely not indicated in patients on ACAP therapy, as our study suggests clinically significant delayed ICH does not occur. Additionally, presenting GCS deviation, LOC, neurological examination findings, clopidogrel, aspirin or combination regimen use may predict ICH, and, in the absence of these findings, HCT may potentially be forgone altogether 9).

For Joseph et al. routine repeat head CT remains an important component in this patient population and can provide useful information 10)

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