Delayed intracranial hemorrhage (ICH) is an uncommon occurrence among patients with mild traumatic brain injury who are on anticoagulant therapy and have a negative initial CT scan. A recent analysis of nearly 600 such patients revealed a delayed ICH incidence rate of just 2%, suggesting that routine extended hospital observation may not be necessary for all patients in this category.
The study examined 596 individuals with a median age of 83, all of whom were on anticoagulant medications and had experienced a mild head injury, defined by a Glasgow Coma Scale score of 13 or higher. The majority of patients were being treated for atrial fibrillation, with smaller numbers taking anticoagulants for deep vein thrombosis or pulmonary embolism. Approximately three-quarters of the patients were on direct oral anticoagulants (DOACs), while the remainder were using vitamin K antagonists.
After an initial negative CT scan, all patients were monitored for 24 hours and underwent a second CT scan. Delayed ICH was identified in 2% of cases, with subarachnoid hemorrhage and subdural hematoma being the most common types. Importantly, none of these patients required neurosurgical intervention, and there were no deaths reported within 30 days, highlighting the relatively benign course of delayed bleeding in this population.
Interestingly, patients who developed delayed ICH were more likely to have experienced high-energy trauma, such as falls from a greater height or motor vehicle accidents, compared to those who remained stable (17% vs 1.7%). Although the incidence of delayed bleeding was higher in patients on vitamin K antagonists than in those on DOACs, the difference was not statistically significant.
Among the small subset of patients who developed delayed hemorrhage, two-thirds experienced additional complications during their hospital stay, most commonly nosocomial infections and delirium. These findings underscore the importance of individualized risk assessment in deciding on the need for observation or discharge.
The study’s findings support a more selective approach to hospitalization for patients on anticoagulants who present with mild head trauma and a normal CT scan. In the absence of additional risk factors such as high-energy mechanisms or clinical instability many such patients could be safely discharged after the initial assessment, potentially reducing healthcare costs and improving patient comfort.
However, further prospective, multicenter studies are needed to validate these findings and inform more definitive clinical guidelines.
