Stop the Bleeding…of Unnecessary Care – Another Strike Against Delayed Head CT

December 22, 2022

Written by John Korducki

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No significant difference in delayed intracranial hemorrhage (dICH) was seen in patients on antithrombotic (AT) medication vs. no AT among patients with repeat CT.

Why does this matter?
Many hospitals have existing protocols regarding delayed repeat head imaging in anticoagulated patients, calling for admission for observation or delayed head imaging, which may add unnecessary cost and burden to the patient and hospital. Yesterday, we learned the rate of dICH was 1.8% in patients on warfarin and 1% among patients on DOACs or no AT.

Stop the bleeding… of unnecessary care
This was a retrospective cohort study of patients ≥55 years presenting with mild head trauma (GCS 14-15) to a selected group of Level I or II trauma centers. 280 of 2,950 patients had repeat head CT, though no criteria for re-scanning were universally established. AT medication included both antiplatelet agents (i.e. aspirin or clopidogrel) and anticoagulants (warfarin or DOACs). They found 16.2% of those on AT received a delayed head CT vs 6.3% of those not on AT. Overall, 7.5% of the 280 that were re-scanned had dICH. Interestingly, those not on AT had dICH more frequently than those who were taking AT: 15/126 (11.9 %) vs. 6/154 (3.9%), respectively. I suspect this was skewed by unmeasured clinical variables leading the provider to repeat a CT. If we assume that all patients who were not rescanned did not suffer dICH, the rate of dICH for those not on AT would be 15/2001 (0.7%) and 6/949 (0.6%) for those taking AT.

Importantly, none of the patients with identified dICH, nor the 2,670 who were not re-scanned, went on to require surgical intervention. No mortality benefits were noted among the groups.

While the retrospective nature and lack of defined indicators for re-scanning across systems limits the interpretation of the data, this study further contributes to a growing body of research demonstrating there is a low incidence of dICH in patients on AT with mild TBI.^1,2,3,4 One study found that the average cost to identify a single dICH was $1.02 million when a universal screening protocol was applied.⁵ In my opinion, the data suggest universal delayed imaging protocols are overly resource intensive and costly. Rather, I believe a provider should carefully consider whom to re-scan based on a patient’s mechanism of injury and comorbidities, with anticoagulation status and dosage as an additional consideration. As always, patient education and discussion of return precautions should be utilized to empower the patient or family to self-identify dICH.

Source
Findings on Repeat Posttraumatic Brain Computed Tomography Scans in Older Patients With Minimal Head Trauma and the Impact of Existing Antithrombotic Use. Ann Emerg Med. 2022 Oct 31;S0196-0644(22)00580-7. doi: 10.1016/j.annemergmed.2022.08.006. Online ahead of print.

Works Cited

1. Chauny JM, Marquis M, Bernard F, et al. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Emerg Med. 2016;51(5):519-528.
2. Miller J, Lieberman L, Nahab B, et al. Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review. J Trauma Acute Care Surg. 2015;79(2):310-313.
3. Liu S, McLeod SL, Atzema CL, et al. Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department [published online ahead of print, 2022 Oct 15]. CJEM. 2022;10.1007/s43678-022-00392-z. doi:10.1007/s43678-022-00392-z
4. Borst J, Godat LN, Berndtson AE, et al. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery. 2021;170:623-627.
5. Li J. Admit all anticoagulated head-injured patients? A million dollars versus your dime. You make the call. Ann Emerg Med. 2012;59:457-459.