Non-Contrast CT Head Without Contrast
For a patient on Eliquis (apixaban) who has fallen, obtain a non-contrast CT head immediately to rule out intracranial hemorrhage—this is the standard of care and the only appropriate initial imaging modality. 1
Initial Imaging Approach
A non-contrast CT head is the definitive imaging study for detecting acute intracranial hemorrhage in anticoagulated patients with head trauma. This applies regardless of whether the patient is on warfarin, DOACs like Eliquis, or antiplatelet agents 1.
When to Image
According to ACR Appropriateness Criteria and ACEP guidelines, CT head is indicated in patients on anticoagulation (including Eliquis) with head trauma if ANY of the following are present 1:
- Any loss of consciousness or post-traumatic amnesia
- Headache or vomiting
- Age >60-65 years
- Glasgow Coma Scale (GCS) <15
- Focal neurologic deficit
- Physical evidence of trauma above the clavicle
- Post-traumatic seizure
- Dangerous mechanism (fall >3 feet/5 stairs, motor vehicle collision)
Critical point: Most clinical practice guidelines recommend CT in ALL patients with head trauma who are on anticoagulation, even with minimal trauma 1. The evidence shows that 5% of asymptomatic elderly patients on anticoagulation will have intracranial hemorrhage after minor head trauma 2.
Why Non-Contrast CT?
- Highly sensitive for detecting acute hemorrhage requiring neurosurgical intervention
- Rapid acquisition (critical in emergency settings)
- Widely available in emergency departments
- No contrast needed—contrast would obscure acute blood and is unnecessary for hemorrhage detection
Other Imaging Modalities Are NOT Appropriate
- CTA head/neck: No role in initial trauma evaluation unless vascular injury is suspected 1
- MRI: More sensitive for subtle injuries but NOT the initial study—too slow, less available, and doesn't change acute management 1
- Skull X-rays: No role whatsoever 1
Special Considerations for Eliquis Patients
Bleeding Risk Profile
Patients on Eliquis have a 3-fold increased risk of bleeding progression compared to non-anticoagulated patients (26% vs 9%) 1. However, recent evidence suggests DOACs like Eliquis may have a more favorable safety profile than warfarin, with lower rates of immediate ICH (3.8% vs 5.0%) and delayed ICH (2.6% vs 3.3%) 3.
The Repeat CT Controversy
You do NOT need routine repeat CT at 24 hours if:
- Initial CT is negative
- Patient remains neurologically intact (GCS 15)
- No new symptoms develop
The evidence strongly supports this approach:
- Zero delayed hemorrhages were found in a cohort of 215 anticoagulated patients with normal initial CT and GCS 14-15 4
- Only 0.5% delayed ICH rate in DOAC patients with negative initial CT, and none required neurosurgical intervention 5
- 1.19% overall delayed ICH rate in anticoagulated patients, with the two cases occurring only in warfarin patients with INR >2.0 6
However, routine repeat CT IS recommended if:
- Initial CT shows ANY traumatic finding 1
- Patient has moderate-to-severe TBI 1
- GCS remains <15 after 24 hours 1
- Any neurologic deterioration occurs 1
Practical Algorithm
Patient on Eliquis + fall → Order non-contrast CT head immediately
If initial CT is NEGATIVE:
If initial CT is POSITIVE:
- Admit for observation
- Obtain routine repeat CT within 24 hours (bleeding progression occurs in 26% of anticoagulated patients) 1
- Consult neurosurgery as appropriate
Common Pitfalls to Avoid
- Don't order contrast-enhanced CT—it obscures acute blood
- Don't obtain MRI as the initial study—too slow and doesn't change acute management
- Don't automatically admit all Eliquis patients for 24-hour observation if initial CT is negative and GCS is 15—this outdated practice is not supported by current evidence 4, 5
- Don't skip imaging in elderly patients on Eliquis even with "minor" trauma—5% will have occult hemorrhage 2