Does a 79-year-old female on anticoagulants (e.g. warfarin, aspirin, direct oral anticoagulant like apixaban or rivaroxaban) require a head CT after a fall without direct head impact or loss of consciousness?

Head CT is Indicated for a 79-Year-Old Female on Anticoagulants After a Fall

Yes, a head CT scan is strongly indicated for a 79-year-old female on anticoagulants who has experienced a fall, even without direct head impact or loss of consciousness. 1, 2

Rationale for Head CT in Anticoagulated Patients

• Patients on anticoagulants have a significantly higher risk of intracranial hemorrhage (ICH) after head trauma compared to non-anticoagulated patients (3.9% vs 1.5%) 1
• The threshold for initial imaging after minor head trauma in patients on anticoagulants is very low due to the potentially serious consequences of missing an early hemorrhage 1
• Advanced age (>60 years) is an additional risk factor that increases the importance of obtaining a head CT 2
• The American College of Emergency Physicians (ACEP) provides a Level B recommendation that noncontrast head CT should be considered in patients with head trauma who have coagulopathy, even without loss of consciousness 1

Important Clinical Considerations

• Even in asymptomatic elderly patients on anticoagulation, intracranial hemorrhage can occur in a relevant proportion after minor trauma to the head 3
• Studies have shown that approximately 5% of symptom-free patients on anticoagulation may have intracranial bleeding after a ground-level fall 3
• While direct oral anticoagulants (DOACs) have a lower incidence of ICH compared to vitamin K antagonists like warfarin (2.6% vs 10.2%), the risk is still higher than in patients without anticoagulation 1
• The absence of neurological symptoms does not reliably exclude intracranial hemorrhage in anticoagulated patients 3, 4

Management Algorithm

1. Obtain a noncontrast head CT scan for all patients on anticoagulants who have experienced a fall, regardless of symptoms or mechanism severity 1, 2
2. If the initial CT is negative and the patient has a normal neurological examination (GCS 15), discharge may be considered with appropriate follow-up instructions 1
3. If the initial CT shows intracranial hemorrhage, plan for follow-up imaging within 24 hours to assess for hemorrhage progression, as patients on anticoagulant medication have a 3-fold increase in frequency of bleeding progression (26% versus 4.8% in non-anticoagulated patients) 2, 5

Pitfalls to Avoid

• Failing to obtain an initial head CT for patients on anticoagulants after a fall, even if the mechanism seems minor or there are no symptoms 2, 3
• Assuming that a patient without focal neurologic deficits or with a normal GCS score does not require imaging 4
• Overlooking the possibility of delayed hemorrhage, which can occur even after an initially negative CT scan 6

In conclusion, given the patient's advanced age (79 years) and anticoagulant use, a head CT is necessary to rule out intracranial hemorrhage, despite the absence of direct head impact or loss of consciousness.