From the Guidelines
Elderly patients with head injuries who are on anticoagulants or antiplatelets, or have other high-risk factors, may not necessarily require repeat head CT scans if they are neurologically intact and have a normal initial CT scan, as the risk of delayed intracranial hemorrhage is low. The decision to perform repeat imaging should be based on clinical judgment, taking into account the patient's overall condition, the presence of high-risk factors, and the potential benefits and risks of repeat imaging 1.
Key Considerations
- Patients on anticoagulants or antiplatelets have a higher risk of intracranial hemorrhage, but the majority of studies suggest that delayed hemorrhage is rare and often not clinically significant 1.
- The timing of repeat imaging depends on clinical status, but typically occurs within 6-24 hours after injury or sooner if deterioration occurs.
- Elderly patients have higher mortality rates from traumatic brain injuries and delayed hemorrhages are more common in this population due to brain atrophy, vascular fragility, and medication effects.
- Early detection of evolving intracranial hemorrhages through appropriate repeat imaging allows for timely neurosurgical intervention when needed.
High-Risk Factors
- Anticoagulant or antiplatelet use
- Initial abnormal CT findings
- Glasgow Coma Scale score less than 15
- Persistent vomiting
- Severe headache
- Post-traumatic seizures
- Signs of increased intracranial pressure
Recommendations
- Repeat head CT scans are not routinely recommended for elderly patients with minor head trauma who are on anticoagulants or antiplatelets, but are neurologically intact and have a normal initial CT scan 1.
- Clear discharge instructions with return precautions are warranted, as up to 5% of these patients may develop delayed intracranial hemorrhage.
- The decision to withhold anticoagulant or antiplatelet medication should be made on a case-by-case basis, weighing the risks and benefits of withholding these medications.
From the Research
Indications for Repeat Head CT in Elderly Head Injury
- The decision to repeat a head CT in elderly patients with head injury is complex and depends on various factors, including the patient's clinical condition, medication use, and initial CT findings 2, 3, 4, 5.
- Patients with a Glasgow Coma Scale (GCS) score of 15 and no focal neurologic deficits who are receiving anticoagulants such as heparin or coumadin may not necessarily require emergency CT 2.
- Low-dose aspirin therapy is not a reason for repeating head CT in traumatic brain injury, as it is not associated with progression of initial insult or clinical deterioration 3.
- However, patients on antiplatelet therapy, particularly those with a history of loss of consciousness, may be at higher risk for intracranial hemorrhage and may require closer monitoring and repeat CT scans 4, 5.
- The use of anticoagulation and antiplatelet medication is a significant factor in the decision to repeat a head CT, and patients on these medications should be carefully evaluated for signs of intracranial hemorrhage 4, 5.
Factors Influencing the Decision to Repeat Head CT
- GCS score: a score of 15 is generally considered indicative of mild head injury, but patients with a score of 15 who are on anticoagulation or antiplatelet therapy may still be at risk for intracranial hemorrhage 2, 4, 5.
- Medication use: anticoagulation and antiplatelet therapy increase the risk of intracranial hemorrhage, and patients on these medications should be carefully monitored 2, 3, 4, 5.
- Clinical condition: patients with focal neurologic deficits or signs of clinical deterioration should undergo repeat CT scans to rule out intracranial hemorrhage 2, 4.
- Initial CT findings: patients with initial CT findings indicative of intracranial injury should undergo repeat CT scans to monitor for progression of the injury 3, 4.
Glasgow Coma Scale (GCS) and Repeat Head CT
- The GCS is a widely used tool for assessing level of consciousness, but its use in practice is often inconsistent and confusing 6.
- Further research is needed to standardize the use of the GCS in practice and to explore its application in assessing level of consciousness in patients with head injury 6.