Management of Head Injury in Patients on Anticoagulants and Chemotherapy

Immediate Imaging and Risk Assessment

Anticoagulated patients have a 3.9% risk of significant intracranial injury versus 1.5% in non-anticoagulated patients, and novel oral anticoagulants (NOACs) carry a 2.6% risk of intracranial hemorrhage, while warfarin carries a 10.2% risk 1
The American College of Emergency Physicians provides Level B evidence that routine repeat imaging is not indicated in patients at baseline neurologic examination with negative initial CT, with a risk of delayed intracranial hemorrhage of 0.6-6% for warfarin and 0.95% for DOACs 2, 3

For patients on warfarin with intracranial hemorrhage, administer 4-factor prothrombin complex concentrate (4F-PCC) plus 5mg intravenous vitamin K to achieve INR <1.5, with a strength of evidence based on clinical guidelines 1
For patients on apixaban or other factor Xa inhibitors with intracranial hemorrhage, use andexanet alfa as the specific reversal agent if available, with a strength of evidence based on clinical trials 2, 1
Obtain repeat head CT within 24 hours in patients with initial CT showing intracranial hemorrhage, as anticoagulated patients have a 3-fold increased risk of hemorrhage expansion (26% versus 9% in non-anticoagulated patients) 2, 1

The American College of Emergency Physicians recommends assessing platelet count and coagulation parameters immediately in chemotherapy patients, as many chemotherapy regimens cause thrombocytopenia, which compounds bleeding risk 4
Administer tranexamic acid (TXA) 1g IV over 10 minutes if intracranial hemorrhage is confirmed, provided treatment can be given within 3 hours of injury, with a strength of evidence based on clinical trials showing a risk ratio of 0.78 (95% CI 0.64-0.95) for head injury-related death 5

Provide clear written discharge instructions including signs of delayed hemorrhage and instructions to return immediately or call 911 if symptoms develop, with a strength of evidence based on clinical guidelines 2, 1
Arrange outpatient follow-up for fall risk assessment and reassessment of anticoagulation risk/benefit ratio, with a strength of evidence based on clinical guidelines 2, 1

The American Society of Hematology recommends holding anticoagulation temporarily in patients with head injury, instructing them to skip the next dose(s) of anticoagulant until evaluated, which may reduce hemorrhage expansion risk if bleeding occurs, although it increases thromboembolic risk 6, 7

The European Society of Anaesthesiology suggests arranging close observation by a responsible adult who can monitor the patient continuously for the next 24 hours with specific instructions on warning signs, such as severe headache, confusion, vomiting, weakness, seizures, worsening drowsiness, slurred speech, vision changes, or inability to wake 6, 7