Guidelines advise performing imaging in those patients on anticoagulants who have suffered minor head injury. We virtually all dutifully obey, because, even though the incidence of intracranial hemorrhage is low – it’s still much higher than zero. But, how high, really? Particularly when they’re sitting there, looking normal, with a GCS of 15?
This systematic review and meta-analysis gathered together 5 studies comprising 4,080 anticoagulated patients with GCS 15 following a head injury. Three of the studies mandated imaging, while the others allowed physician discretion with observation, telephone, and chart-review follow-up to ascertain outcomes. The vast majority of patients were on Vitamin K antagonists, and most mechanisms of injury – where documented – were falls.
Overall, there were 209 (5%) patients with ICH after their fall, nearly all of which were diagnosed at the index visit. There was a wide range of findings, ranging from 4% in the largest studies to 22% in the smaller. However, the larger studies were the ones with the least-complete follow-up after the index event. Therefore, these authors’ random effects analysis and sensitivity analysis generated higher estimates of the incidence, up to 10.9%.
So, while yield is low, we’re still far from having a strategy to support selective scanning to improve value. While it is unlikely many of these would have neurosurgical intervention indicated, a substantial portion likely underwent anticoagulation reversal to prevent further morbidity or mortality. While resource stewardship is always an important consideration, it is unlikely we will anytime soon be altering our approach to minor head injury in the context of anticoagulation.
“Incidence of intracranial bleeding in anticoagulated patients with minor head injury: a systematic review and meta-analysis of prospective studies”