What is the management approach for a 91-year-old patient on Eliquis (apixaban) who has fallen and hit his head, presenting with scalp bruising and a possible contusion?

Management of Head Injury in 91-Year-Old Patient on Apixaban

For a 91-year-old patient on apixaban who fell and hit their head one week ago with bruising on the scalp and possible contusion, immediate CT imaging of the brain is required to rule out intracranial hemorrhage, which may require reversal of anticoagulation with andexanet alfa if bleeding is detected.

Initial Assessment

• Urgent evaluation is critical due to:
  • Advanced age (91 years)
  • Anticoagulation with apixaban (Eliquis)
  • History of head trauma
  • Presence of scalp bruising
  • Possible confusion (suggesting neurological symptoms)
  • Delayed presentation (one week after injury)

Diagnostic Approach

1. Immediate head CT scan to evaluate for:

   • Intracranial hemorrhage (subdural, epidural, subarachnoid, or intraparenchymal)
   • Signs of mass effect or midline shift
   • Evidence of skull fracture

2. Laboratory tests:

   • Complete blood count
   • Coagulation profile
   • Anti-factor Xa activity (if available) to assess apixaban activity 1
   • Renal function (impacts apixaban clearance)

Management Algorithm Based on CT Findings

If CT Shows Intracranial Hemorrhage:

1. Immediately discontinue apixaban 2, 1

2. Administer reversal agent:

   • First-line: Andexanet alfa (specific reversal agent for apixaban) 2, 1

     • Dosing based on last apixaban dose and time since administration
     • Reduces anti-FXa activity by approximately 92% for apixaban 1

   • Alternative if andexanet alfa unavailable: Four-factor prothrombin complex concentrate (PCC) at 25-50 U/kg 2, 1

     • The 2023 WSES guidelines recommend 4F-PCC for life-threatening bleeding in critical organs like the central nervous system 2

3. Neurosurgical consultation for evaluation of potential surgical intervention

4. Admission to ICU for close neurological monitoring

If Initial CT is Negative:

Despite a negative initial CT, patients on apixaban remain at risk for delayed intracranial hemorrhage, though this risk appears lower than with warfarin.

1. Consider observation period:

   • The risk of delayed intracranial hemorrhage in patients on DOACs (including apixaban) is approximately 0.95% based on recent research 3
   • This risk increases to approximately 4-4.5% if the patient is also on antiplatelet therapy 2, 3

2. Options based on risk assessment:

   • Higher risk features (confusion, severe headache, focal neurological deficits):

     • Admission for 24-hour observation
     • Repeat CT scan before discharge 2

   • Lower risk features (no neurological symptoms, normal mental status):

     • Discharge may be considered with clear return precautions 2, 3
     • Recent evidence suggests patients on DOACs without concurrent antiplatelet therapy may not require admission and repeat CT after a negative initial scan 3

Special Considerations

• Age is a significant risk factor: At 91 years, this patient has increased risk of both bleeding and poor outcomes from intracranial hemorrhage

• Timing of presentation: Presentation one week after injury is concerning as delayed hemorrhage can occur days after initial trauma 2

• Confusion assessment: Determine if confusion is new (suggesting intracranial pathology) or pre-existing

• Fall risk evaluation: Address factors contributing to falls to prevent recurrence

Follow-up and Anticoagulation Management

If no intracranial hemorrhage is detected and anticoagulation was temporarily held:

1. Reassess indication for anticoagulation

2. Restart anticoagulation:

   • For standard risk patients: restart full anticoagulation 7-14 days after confirmed hemostasis 1
   • For high thrombotic risk: consider prophylactic doses initially (24-72 hours after hemostasis) 1

3. Fall prevention strategies to reduce risk of recurrent trauma

Pitfalls to Avoid

• Do not delay imaging: Even with delayed presentation, CT imaging is essential
• Do not assume bruising is superficial: External signs may not correlate with severity of intracranial injury
• Do not restart anticoagulation prematurely: Balance thrombotic and hemorrhagic risks
• Do not overlook mild symptoms: Subtle neurological changes in elderly patients may indicate significant pathology
• Do not rely solely on standard coagulation tests: They may not reliably reflect apixaban's anticoagulant effect 1, 4