Should an elderly patient on chronic anticoagulation with Eliquis (apixaban) who presented to the clinic 2 days after a closed head injury with a resolving hematoma and significant ecchymosis, but no loss of consciousness or other symptoms, undergo a CT scan of the head today?

Should This Patient Get a CT Scan Today?

No, a CT scan is not indicated today for this elderly patient on Eliquis who is 2 days post-injury with a resolving hematoma, no loss of consciousness, and no neurological symptoms. 1, 2

Clinical Reasoning

This patient has already passed the critical window for delayed intracranial hemorrhage without developing concerning symptoms. The key decision point is whether an initial CT was obtained at the time of injury, which the question does not explicitly state but is implied by the clinical presentation.

If No Initial CT Was Obtained (Most Likely Scenario)

The patient should have received an initial CT scan at the time of injury 2 days ago, but obtaining one now is not indicated given the clinical course. 1, 2

• The American College of Emergency Physicians provides Level B recommendation that noncontrast head CT should be obtained in patients with head trauma who have coagulopathy, even without loss of consciousness, at the time of initial presentation 1
• Patients on apixaban have a 2.6% risk of intracranial hemorrhage after head trauma compared to 1.5% in non-anticoagulated patients, making initial imaging essential 1, 2
• However, the risk of delayed intracranial hemorrhage in patients on DOACs like apixaban is only 0.95%, and importantly, none of these patients required neurosurgical intervention 3

Current Clinical Assessment (2 Days Post-Injury)

The patient's presentation strongly suggests no intracranial pathology:

• Resolving hematoma - The fact that the hematoma has gotten smaller indicates normal healing without ongoing bleeding 1
• No loss of consciousness - This is a favorable prognostic indicator 1, 2
• No neurological symptoms - The patient denies headache, confusion, vomiting, weakness, or altered mental status 1, 2
• 48 hours post-injury - Most hemorrhage expansion occurs within the first 6 hours, and the patient has passed this critical window asymptomatically 1

Evidence Against Delayed Imaging

• The American College of Emergency Physicians recommends against routine repeat imaging in patients at baseline neurologic examination after minor head injury on anticoagulants, as the risk of delayed hemorrhage requiring intervention is extremely low (<1%) 1, 2
• In a study of 314 patients on DOACs with negative initial CT, only 0.95% developed delayed intracranial hemorrhage, and none required neurosurgical intervention 3
• Performing unnecessary imaging in stable patients increases costs and radiation exposure without changing management 1

Management Recommendations

Immediate Actions

• Perform focused neurological examination including Glasgow Coma Scale, cranial nerve assessment, motor/sensory function, and gait stability 1, 2
• Document the external injury - photograph or describe the hematoma and ecchymosis for medicolegal purposes 1
• Verify anticoagulation indication - ensure the risk-benefit ratio still favors continuing apixaban 1, 2

Patient Education

Provide clear discharge instructions with specific warning signs that warrant immediate return to the ED or calling 911: 1, 2, 4

• Severe or worsening headache
• Confusion or altered mental status
• Repeated vomiting
• New weakness or numbness
• Seizures
• Worsening drowsiness or difficulty waking
• Slurred speech or vision changes

Follow-Up Care

• Fall risk assessment - arrange outpatient evaluation to prevent future injuries 1, 2, 4
• Anticoagulation reassessment - consider whether the indication for apixaban still outweighs bleeding risk in this elderly patient with fall history 1, 2
• Continue apixaban - do not discontinue anticoagulation without specialist consultation, as thromboembolic risk may outweigh the minimal risk of delayed hemorrhage at this point 1, 2

Common Pitfalls to Avoid

• Obtaining unnecessary imaging in neurologically intact patients beyond the acute injury window, which increases healthcare costs without improving outcomes 1, 2
• Discontinuing anticoagulation reflexively without considering the indication and thromboembolic risk 1, 2, 4
• Failing to provide clear return precautions - patients and families must understand warning signs of delayed hemorrhage, even though the risk is very low 1, 2

Special Consideration

If this patient had never received an initial CT scan at the time of injury, this represents a deviation from guidelines. However, given that 48 hours have passed with clinical improvement and no neurological symptoms, the window for detecting actionable pathology has essentially closed. The patient's improving clinical course provides reassurance that no significant intracranial injury occurred. 1, 3