Admission and Repeat Head CT for Patients on Warfarin with Minor Head Injury?

This approach identifies most delayed intracranial bleeds, but whether it changes patient outcomes and justifies the increased resources is not clear.


Current U.S. guidelines recommend head computed tomography (CT) for all patients taking warfarin who experience minor head injury. In a prospective study at a single emergency department in Italy, researchers evaluated outcomes in 97 adults with minor head injury who were taking warfarin, had normal initial head CT scans, and were admitted for 24-hour observation and repeat head CT (consistent with European guidelines). Minor head injury was defined as any head trauma other than superficial face injuries and Glasgow Coma Scale score of 14–15 regardless of presence or absence of loss of consciousness.

Ten patients declined the repeat CT scan (all were asymptomatic at 30 days). Of the 87 remaining patients, 5 (6%) had lesions detected on repeat CT. Of these five patients, two were discharged because their lesions were considered inconsequential, and three were admitted, with one undergoing craniotomy for subdural hematoma. Only one of the five patients with positive repeat CT scans demonstrated new neurological symptoms during the observation period. Two patients who were discharged after normal repeat CT scans were readmitted with symptomatic (confusion, headache) delayed subdural hematoma; neither patient required surgery.

Four of the five patients with positive repeat CT scans and both patients who were readmitted with delayed subdural hematoma had international normalized ratios (INRs) >3; however, the study was not powered to determine the statistical significance of predictors of intracranial hemorrhage (ICH).


Citation(s):

Menditto VG et al. Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol. Ann Emerg Med 2012 Jan 13; [e-pub ahead of print].