Management of Head Injury in Anticoagulated Patient with Neurological Symptoms
Obtain an immediate non-contrast head CT scan and hold the blood thinner until intracranial hemorrhage is excluded. 1, 2
Immediate Actions in the Emergency Department
Neuroimaging
- Perform urgent non-contrast head CT regardless of symptom severity or mechanism of injury 1, 2
- The threshold for imaging is very low because anticoagulated patients have 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients 1, 2
- Giddiness and blurred vision after head trauma represent concerning neurological symptoms that mandate immediate imaging 1
Blood Pressure Management
- In patients with acute intracerebral hemorrhage and systolic BP ≥220 mmHg, carefully lower BP with intravenous therapy to <180 mmHg 1
- For systolic BP <220 mmHg, immediate aggressive BP lowering is not recommended 1
- Target systolic BP of 140 mmHg is recommended within 6 hours of symptom onset if hemorrhage is confirmed, strictly avoiding SBP <110 mmHg 1
If Initial CT Shows Intracranial Hemorrhage
Anticoagulation Reversal
- Immediately discontinue the blood thinner and reverse anticoagulation 1, 2
- For warfarin with INR ≥2.0: administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5mg intravenous vitamin K 1, 2
- For factor Xa inhibitors (apixaban, rivaroxaban): use andexanet alfa if available; if unavailable, use 4F-PCC 1, 2
- For dabigatran: administer idarucizumab 1
- Obtain immediate neurosurgical consultation 2
Follow-up Imaging
- Repeat head CT within 24 hours because anticoagulated patients have 3-fold increased risk of hemorrhage expansion (26% versus 9%) 2, 3
- Most hemorrhage expansion occurs within the first 6 hours 3
If Initial CT is Negative
Observation Decision
- For neurologically intact patients with negative initial CT, routine repeat imaging or admission is not necessary 1, 2, 4
- Brief observation (4-6 hours) may be considered for high-risk features including: 2, 4
- Age >80 years
- History of loss of consciousness or amnesia
- Glasgow Coma Scale <15
- Concomitant use of multiple anticoagulant/antiplatelet agents
Risk of Delayed Hemorrhage
- The risk of delayed intracranial hemorrhage after negative initial CT is low (0.6-6%) 1, 4
- Delayed hemorrhage rarely requires neurosurgical intervention 1, 4
- Patients on NOACs have only 1.5% delayed ICH rate with none requiring surgery 4
Anticoagulation Management
- Continue the blood thinner if initial CT is negative and patient is neurologically intact 2, 4
- Consider the indication for anticoagulation, as thromboembolic risk may outweigh the small risk of delayed hemorrhage 2, 4
- One study showed only 1.1% suffered thromboembolic events when anticoagulation was held, but 41.2% had re-hemorrhage if anticoagulation was restarted with residual subdural hematoma 5
Discharge Instructions and Follow-up
Patient Education
- Provide clear written instructions about signs of delayed hemorrhage: severe headache, confusion, vomiting, weakness, seizures 2
- Instruct patient to return immediately or call 911 if these symptoms develop 2
Outpatient Management
- Arrange fall risk assessment 2
- Reassess anticoagulation risk/benefit ratio 2
- Blood pressure should be controlled with antihypertensive medications if elevated BP persists after acute period 1
Common Pitfalls to Avoid
- Failing to obtain initial CT imaging after any head trauma in anticoagulated patients, even with minor mechanisms like ground-level falls 1, 2
- Unnecessarily admitting patients with negative initial CT for repeat imaging, which increases costs without improving outcomes 1, 2
- Discontinuing anticoagulation without considering the indication and thromboembolic risk 2, 4
- Delaying repeat imaging when neurological deterioration occurs 3
- Aggressively lowering BP <110 mmHg, which can worsen outcomes 1