What is the management plan for a patient with a subgaleal hematoma and dizziness after trauma, with a normal CT (Computed Tomography) scan result and possible anticoagulant or antiplatelet medication use?

Management of Subgaleal Hematoma with Dizziness After Trauma and Normal CT Scan

For a patient with subgaleal hematoma, dizziness, and normal CT scan after trauma, discharge home is safe if the patient is neurologically intact at baseline, regardless of anticoagulant or antiplatelet use, with clear return precautions and adequate social support. 1

Risk of Delayed Intracranial Hemorrhage

The risk of delayed intracranial hemorrhage (ICH) after a normal initial CT scan is extremely low across all medication categories:

• Warfarin patients: 0.6% risk of delayed ICH, with none requiring neurosurgical intervention 2
• Clopidogrel patients: 0% delayed ICH in the largest study 2
• NOACs (including apixaban): 1.5% developed delayed ICH on repeat scanning, with zero deaths and zero neurosurgical interventions 2
• Aspirin monotherapy in elderly (≥65 years): 4% delayed ICH rate, with only one requiring neurosurgery 2

The American College of Emergency Physicians provides Level B recommendations that patients on anticoagulants or antiplatelets with normal initial CT and baseline neurological examination do not require routine repeat imaging or hospital admission. 1

Discharge Criteria

You can safely discharge this patient if ALL of the following are met:

• Neurologically intact at baseline examination (GCS 15, no focal deficits) 1
• Initial head CT shows no hemorrhage (which is the case here) 1
• Adequate social support for home observation 1
• Clear discharge instructions provided regarding symptoms of delayed hemorrhage 1

The subgaleal hematoma itself, while potentially dramatic in appearance, does not change management when the CT is normal. 3 Most subgaleal hematomas resolve spontaneously without aspiration or drainage. 3

Anticoagulation Management

Do not routinely withhold anticoagulation or antiplatelet medications after negative initial CT in neurologically intact patients. 1 The thromboembolic risk from stopping these medications may outweigh the small risk (<1%) of delayed hemorrhage requiring intervention. 1

• Continue warfarin, NOACs, clopidogrel, or aspirin as prescribed 2
• Only withhold anticoagulation in consultation with a specialist if there are specific concerns 1

Observation Considerations

Brief observation (4-6 hours) may be warranted if the patient has any of these higher-risk features:

• Age >80 years 1
• History of loss of consciousness or amnesia 1
• GCS <15 (though your patient appears neurologically intact) 1

However, even with these features, 24-hour admission with routine repeat CT is not supported by evidence for patients with normal initial CT. 2, 1

Discharge Instructions

Provide explicit instructions to return immediately for:

• Worsening or severe headache 1
• Vomiting 1
• Confusion or altered mental status 1
• New weakness or numbness 1
• Seizure activity 1
• Vision changes 1

Common Pitfalls to Avoid

• Performing unnecessary repeat CT scans in stable patients with negative initial CT increases costs and radiation exposure without changing management 1
• Unnecessarily discontinuing anticoagulation without considering thromboembolic risk is a critical error 1
• Admitting all anticoagulated patients for observation despite normal CT and neurological examination is not evidence-based 2, 1
• Failing to arrange outpatient follow-up for fall risk assessment and anticoagulation risk-benefit evaluation 1

Special Note on Dizziness

The dizziness in this patient is likely related to the trauma itself or the subgaleal hematoma causing local discomfort, rather than intracranial pathology, given the normal CT. 3 If dizziness is severe, positional, or associated with nystagmus, consider vestibular causes, but this does not change the management algorithm for the head trauma itself.