Impact of anticoagulant therapy on delayed intracranial haemorrhage after traumatic brain injury: A study on the role of repeat CT scans and extended observation.

Abstract

Introduction: Traumatic brain injury (TBI) is a major contributor to emergency department (ED) visits worldwide, with older adults being particularly susceptible due to fall-related injuries. The widespread use of anticoagulants, including direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs), raises concerns about the risk of delayed intracranial haemorrhage (dICH), even in cases where the initial head computed tomography (CT) scan shows no abnormalities. The optimal strategies for managing and monitoring these patients remain a subject of ongoing debate.

Materials and methods: We conducted a monocentric retrospective observational study at Santa Croce e Carle Hospital, Cuneo, Italy, from January 2019 to August 2024. We included patients aged ≥18 years, on chronic anticoagulant therapy, presenting with mild TBI (GCS ≥13) and a negative initial CT scan. All patients underwent a second CT after 24 h of observation, regardless of clinical changes. The primary outcome was the incidence of dICH. Secondary outcomes included neurosurgical interventions and 30-day mortality.

Results: The study included 596 patients (median age 83 years; 46.5 % male). Most patients were on DOACs (74.5 %), and falls were the most common trauma mechanism (90.4 %). dICH was diagnosed in 2 % of patients (n = 12), with subarachnoid haemorrhage and subdural hematoma being the most frequent findings (5 patients each). None of the dICH cases required neurosurgical intervention or resulted in mortality at 30 days. Patients with dICH were more likely to have a GCS <15 upon arrival (16.7 % vs. 3.9 %; p = 0.17) and experienced high-energy trauma mechanism, (16.7 % vs. 1.7 %; p = 0.044); among patients with dICH, 41.7 % were on VKA therapy, compared to 25.2 % of patients without dICH (p = 0,33). Complications during hospitalization, primarily nosocomial infections and delirium, occurred in 66 % of patients hospitalized for dICH.

Conclusion: Our findings confirm that dICH after TBI in anticoagulated patients with a negative initial CT is rare and typically benign. Routine prolonged observation and repeat CTs may not be necessary for all patients, particularly those without high-risk factors; individualized management based on clinical risk factors could minimize unnecessary hospitalizations, reduce complications, and optimize healthcare resources.