Do I need an MRI for a patient with atraumatic intracranial hemorrhage (ICH) on Eliquis (apixaban) with a stable interval CT scan?

MRI is Generally Not Needed for Atraumatic ICH on Eliquis with Stable Interval CT

For a patient with atraumatic (spontaneous) intracranial hemorrhage on apixaban with a stable interval CT scan, MRI is not routinely indicated unless there are persistent unexplained neurologic deficits or concern for an underlying structural lesion.

When MRI is NOT Needed

• If your patient has stable neurologic examination and stable hemorrhage on interval CT, no further imaging is required 1, 2
• The American Heart Association guidelines recommend follow-up CT scans at approximately 6 and 24 hours after spontaneous ICH onset to exclude hemorrhage expansion in patients with stable examination 1
• Once stability is documented on CT (typically by 24 hours), routine additional imaging provides minimal clinical benefit 3
• A retrospective study of 833 patients with initially stable repeat imaging found progression occurred in only 1.9%, and most required no change in management 3

When MRI IS Indicated

MRI should be obtained if:

• Persistent neurologic deficits remain unexplained after stable CT 1
• Suspicion for underlying structural lesion (e.g., vascular malformation, tumor, cavernoma) exists, particularly in:
  • Younger patients without hypertension 1
  • Lobar hemorrhages in non-hypertensive patients 1
  • Unusual hemorrhage locations (e.g., sylvian fissure) 1
  • Isolated intraventricular hemorrhage 1

Which MRI Sequences to Order

If MRI is indicated, order:

• MRI brain with and without gadolinium 1, 4
• MRA head and neck (to evaluate for vascular malformations or aneurysms) 1
• Include gradient-echo (GRE) or susceptibility-weighted imaging (SWI) sequences for hemorrhage detection 1, 5

Critical Management Points for Anticoagulated Patients

• Anticoagulated patients have 3-fold higher risk of hemorrhage progression (26% vs 9%) 1, 2
• Routine repeat CT at 6 and 24 hours is strongly supported for patients on apixaban with ICH, regardless of neurologic stability 1, 2
• After documented stability at 24 hours with normal neurologic exam, further routine imaging is not necessary 2, 3

Common Pitfalls to Avoid

• Ordering routine follow-up MRI after negative initial MRI/MRA: A study of 113 patients with spontaneous ICH and negative initial MRI/MRA found zero underlying structural lesions on delayed follow-up MRI (mean 105 days later) 4
• Performing MRI in the acute phase for management decisions: While MRI is more sensitive than CT for small lesions, it rarely changes acute management 1
• Failing to obtain repeat CT in anticoagulated patients: Even with stable exam, these patients require documented imaging stability due to higher progression risk 2

Practical Algorithm

1. Initial presentation: Non-contrast head CT (already done)
2. Interval CT at 6 hours: Check for hemorrhage expansion 1, 2
3. Interval CT at 24 hours: Document final hemorrhage volume if stable 1, 2
4. If stable at 24 hours with normal exam: No further imaging needed 2, 3
5. If unexplained deficits persist: Consider MRI brain with/without contrast + MRA 1