Immediate Head CT Scan Required
This patient requires an urgent non-contrast head CT scan to evaluate for delayed intracranial hemorrhage, given the combination of elevated INR (1.43), persistent symptoms 2 weeks post-head trauma, and concerning neurological complaints. 1, 2
Critical Risk Factors Present
This patient has multiple high-risk features that mandate neuroimaging:
- Elevated INR (1.43) with head trauma: Patients with anticoagulation abnormalities have a relative risk of 1.88 for significant intracranial injury compared to those without coagulopathy 1
- Delayed symptom onset: 18% of patients who deteriorate after head injury do so between days 2-7, making the 2-week timeline of persistent symptoms particularly concerning 2
- Persistent headache and dizziness: These are established predictors of abnormal CT findings in mild traumatic brain injury patients, especially when symptoms worsen or fail to resolve 2, 1
Immediate Diagnostic Approach
Primary Imaging
- Non-contrast head CT scan immediately: This is the first-line imaging study for post-head injury evaluation with coagulopathy 1, 2
- The elevated PT/INR (even at 1.43) significantly increases risk for delayed intracranial hemorrhage, including subdural, epidural, or parenchymal bleeding 3, 4
If CT is Negative but Symptoms Persist
- Consider brain MRI with and without contrast: MRI has superior sensitivity for detecting subtle traumatic brain injuries and posterior fossa lesions affecting vestibular pathways that could explain persistent dizziness 1, 2
Management During Evaluation
Admission and Monitoring
- Hospital admission with close neurological observation for 24-72 hours in a monitored setting with serial neurological assessments 5
- Perform hourly assessments of Glasgow Coma Scale, pupillary responses, motor strength, and orientation 5
- Maintain normotension and adequate cerebral perfusion 5
Coagulopathy Considerations
- The PT/INR of 1.43 (normal <1.20) represents a 19% elevation above normal, placing this patient at increased risk 1
- PT/INR is more sensitive than aPTT for detecting reduced coagulation factor levels in trauma patients (84% vs 50% sensitivity) 6
- Even without prescribed anticoagulation, trauma-induced coagulopathy occurs in 8% of isolated head injury patients and is associated with a relative risk of 2.9 for traumatic brain injury 7
Warning Signs Requiring Immediate Neurosurgical Consultation
The patient should return immediately or neurosurgery should be consulted emergently if any of the following develop 1, 5:
- Repeated vomiting
- Worsening headache
- New focal neurological deficits
- Confusion or abnormal behavior
- Increased sleepiness or loss of consciousness
- Seizures
- Signs of herniation or decreased Glasgow Coma Scale
Common Pitfalls to Avoid
- Do not discharge based on "mild" symptoms alone: The combination of elevated INR, elderly status (implied by coagulopathy workup), and confirmed head trauma creates high risk for deterioration even with seemingly stable presentation 5, 3
- Do not rely on home observation: Frequent waking or pupil assessment at home is not supported by literature and is not recommended for patients with these risk factors 1
- Do not delay imaging: The mortality rate in anticoagulated patients with head injury can reach 50%, far exceeding non-anticoagulated patients with similar injuries 3
Post-Imaging Management
If CT shows intracranial hemorrhage with elevated INR:
- Rapid normalization of coagulopathy is imperative 4
- Prothrombin complex concentrate provides faster INR normalization (331 minutes) compared to vitamin K and fresh-frozen plasma (738 minutes) 4
If CT is negative: