Authors: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) and Adrianna Levesque (EM Senior Resident at SAUSHEC, US Army) // Edited by: Alex Koyfman, MD (EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital, @EMHighAK) & Justin Bright, MD (Senior Staff Physician, Henry Ford Hospital)

EMS wheels in a 74 year-old male with a chief complaint of headache after tripping over the stairs in his home and hitting his head on the railing. He did not lose consciousness and has had no nausea/vomiting, weakness, or confusion. His wife arrives and states he is on warfarin for his chronic atrial fibrillation. He missed his last INR check last week, as they were gone on vacation, but she swears that he is “always between 2 to 3.”

His vitals are normal, and his neurologic examination including mental status, gait, cranial nerves, motor, sensory, and reflexes are normal. He has no neck pain. His INR returns at 2.5, and studies including CT (computed tomography) of the head and C spine are normal.

With his INR and clinical status, what is his risk of delayed intracerebral hemorrhage (ICH)? Should he be reversed? What about other anticoagulant medications? Does he warrant admission, observation, or discharge?

Background

Traumatic brain injury (TBI) is a common ED complaint, with over 1.3 million ED visits. Elderly patients in particular are at increased risk due to increased fall risk, cerebral atrophy, comorbidities, and anticoagulation use. Patients older than 65 years account for 10% of ED visits and 30% of ED admissions for TBI. Patients with anticoagulation use have demonstrated increased rates of ICH and mortality, and at the same time, anticoagulant use has increased.1-3 Unfortunately, all of the head CT rules including NEXUS-II, Canadian CT, and New Orleans criteria exclude anticoagulated patients.4-8

The Quandary

As you can see with the increasing number of head injury patients and increase in anticoagulant use, emergency physicians (EPs) will be faced with managing these patients more frequently. Studies demonstrate that ICH in patients on warfarin varies from 6.2% to 29%.9-11 ICH rates increase with INR level, with an OR of 2.59 with INR > 2.0.3 Thus, almost all providers advocate head CT for these patients on presentation to an ED. However, what are the implications of a negative initial head CT on patient outcome and disposition? The current European guidelines suggest a period of observation and repeat imaging. Other trauma centers differ in their protocols for managing these patients, with some advocating for discharge home if a caregiver who can observe the patient is present, the head CT is normal, and the neurologic examination is normal, and others advocating observation unit placement with or without repeat head imaging.12-14

For patients with altered mental status, abnormal GCS, abnormal neurologic examination, immediate CT and admission are warranted with consideration of anticoagulation reversal.15,16 However, patients with normal mental status and examination present a quandary in terms of disposition. Admit? Observe? Discharge home with follow up?

The Literature

With these dilemmas facing physicians, researchers have sought answers in order to provide safe, effective care. Several studies have evaluated the incidence of delayed ICH following a normal head CT, potentially affecting patient disposition. These studies found a delayed ICH rate of 0.6% to 6% for warfarin.17-20 However, were these delayed ICH clinically significant by affecting patient outcome or treatment? If a diagnosed ICH does not affect patient outcome/treatment, this surrogate outcome of ICH diagnosed from imaging should be questioned. In these studies, the rate of death or neurosurgical intervention ranged from 0 to 1.1%. Two recent meta-analyses bring into question the need to admit these patients with such a low intervention rate for intracranial hemorrhage discovered on imaging.21,22 Another study found that rebleed occurred between days 2 through 28.23

For antiplatelet therapy with warfarin, the major bleeding risk is increased compared to warfarin therapy alone. Combination of aspirin and warfarin has a hazard ratio (HR) of 1.83, with clopidogrel and warfarin HR of 3.08.24 For clopidogrel alone, a study in 2012 demonstrated a 12% rate of ICH on initial head CT, with none of the 243 patients demonstrating a head bleed on repeat CT within a two week time period.19

New generation anticoagulants such as dabigatran are being utilized with increasing frequency. One study in 2015 compared dabigatran versus warfarin for ICH in geriatric falls. This study found an initial rate of ICH of 12.5% for the cohort, with no difference between the two patient groups in mortality and hospital/ICU length of stay. Patients on warfarin experienced a 13.1% rate of ICH, while those on dabigatran demonstrated a rate of 8.3%.25

The Cause

Consideration of the cause of the TBI is important, as well as evaluation for other injuries. The majority of these studies enroll geriatric patients with a ground level fall. Over 80% of the patients in these studies were geriatric, and young adults in trauma did not have a significant place in these studies. Further, older patients vary in terms of frailty, functional status, social situation, dementia, delirium, and prior falls.26

If the patient fell and/or experienced syncope, evaluate why the patient fell. Multiple risk factors for a fall exist including a history of prior falls, psychoactive medications, impaired hearing/eyesight, poor proprioception, and loss of mobility. Management of the elderly patient with a fall in summary must take into account the cause of the fall, assessment of injuries, risk of future falls, provide a safe discharge plan if going home, and a plan for prevention.

If a fall was mechanical and is the cause of TBI, evaluate the patient’s social situation.26,27

Providers must keep in mind other sites of injury and complete a full evaluation. Injuries to the gastrointestinal tract, liver, spleen, and kidney are actually more likely to occur as opposed to ICH. However, if patients die, the most significant injury is ICH and skull fracture.26

Conclusions

With all of this recent literature, what should you do? First, obtain an initial head CT for anticoagulated patients, even if their neurologic exam is normal. If the exam is abnormal or the patient is altered, consider reversal of the anticoagulant agent before obtaining head CT, with admission. If the initial head CT is normal and the patient’s examination is normal, consider discharge with follow up if a reliable caregiver is present. Education of the patient and caregiver is vital, with strict return precautions and follow up.23 If patient follow up is questionable, admission is needed.

References/Further Reading:

Centers for Disease Control and Prevention: Vital Statistics. Available at: http://www.cdc.gov/nchs/vitalstats.htm. Langlois JA, Rutland-Brown W, Thomas KE: Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2006. Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: analysis of the New York State Administrative Database. J Trauma. 2007 Sep;63(3):519-24. Indications for Computed Tomography in Patients with Minor Head Injury, NEJM 2000; 343: 100-105. Clinical Prediction or Decision Rule The Canadian CT Head Rule for Patients with Minor Head Injury, Lancet 2001; 357: 1391-1396. Clinical Prediction or Decision Rule Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients with Minor Head Injury, JAMA 2005; 294: 1511-1518. Developing a Decision Instrument to Guide Computed Tomographic Imaging of Blunt Head Injury Patients (NEXUS II), J Trauma 2005; 59: 954-959. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519-25. Brewer ES1, Reznikov B, Liberman RF, Baker RA, Rosenblatt MS, David CA, Flacke S. Incidence and predictors of intracranial hemorrhage after minor head trauma in patients taking anticoagulant and antiplatelet medication. J Trauma. 2011 Jan;70(1):E1-5. Gittleman AM1, Ortiz AO, Keating DP, Katz DS. Indications for CT in patients receiving anticoagulation after head trauma. AJNR Am J Neuroradiol. 2005 Mar;26(3):603-6. Li J, Brown J, Levine M. Mild head injury, anticoagulants, and risk of intracranial injury. Lancet. 2001 Mar 10;357(9258):771-2. Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760-6. McGonigal M. Delayed Intracranial Hemorrhage in Patients on Anticoagulants. The Trauma Professional’s Blog. http://regionstraumapro.com/post/128846265035. Rendell S. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: observation is unnecessary following a normal CT brain in warfarinised head injuries: an update. Emerg Med J. 2014;31(4):339Y342. Reddy S, Sharma R, Grotts J, Ferrigno L, Kaminski S. Incidence of intracranial hemorrhage and outcomes after ground-level falls in geriatric trauma patients taking preinjury anticoagulants and antiplatelet agents. Am Surg. 2014 Oct;80(10):975-8. Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med. 2015 Feb;48(2):137-42. Menditto VG, Lucci M, Polonara S. 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;59:451-45. Kaen A, Jimenez-Roldan L, Arrese I, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma 2010;68:895-898. Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and pre-injury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-468. Peck KA, Sise CB, Shackford SR, et al. Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma 2011 Dec;71(6):1600-4. Cohn B, Keim SM, Sanders AB. Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med. 2014 Mar;46(3):410-7. Miller J, Lieberman L, Nahab B, Hurst G, Gardner-Gray J, Lewandowski A, Natsui S, Watras J. Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review. J Trauma Acute Care Surg. 2015 Aug;79(2):310-3. Schoonman GG, Bakker DP, Jellema K. Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization. Eur J Neurol. 2014 Jul;21(7):1021-5. Hansen ML, Sørensen R, Clausen MT, Fog-Petersen ML, Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010 Sep 13;170(16):1433-41. Pozzessere A, Grotts J, Kaminski S. Dabigatran Use Does Not Increase Intracranial Hemorrhage in Traumatic Geriatric Falls When Compared with Warfarin. Am Surg. 2015 Oct;81(10):1039-42. Boltz MM, Podany AB, Hollenbeak CS, Armen SB. Injuries and outcomes associated with traumatic falls in the elderly population on oral anticoagulant therapy. Injury. 2015 Sep;46(9):1765-71. Helman A, Melady D, Lee J. Episode 34: Geriatric Emergency Medicine. Emergency Medicine Cases. http://emergencymedicinecases.com/episode-34-geriatric-emergency-medicine/