Imaging in Anticoagulated Patients with Head Trauma

Introduction to Imaging Guidelines

The American College of Radiology recommends that a head CT scan should be performed in anticoagulated patients who have suffered a fall, regardless of the presence or absence of neurological symptoms 1, 2, 3
The American College of Emergency Physicians (ACEP) recommends as a level A indication to perform a non-contrast head CT scan in patients with head trauma and coagulopathy, even in the absence of loss of consciousness or post-traumatic amnesia 1, 2

Patients with coagulopathy (including those taking anticoagulants) have a higher risk of intracranial hemorrhage after head trauma, with a significantly higher incidence (3.9%) compared to non-anticoagulated patients (1.5%) 4, 5
Most clinical practice guidelines recommend performing a CT scan in all patients with head trauma and coagulopathy, defined as any alteration of coagulation or bleeding diathesis, including medications such as warfarin and other anticoagulants 2, 3

Level A Recommendation: Non-contrast head CT scan is indicated in patients with head trauma with loss of consciousness or post-traumatic amnesia if they present with one or more of the following: headache, vomiting, age >60 years, drug or alcohol intoxication, short-term memory deficits, physical evidence of trauma above the clavicle, post-traumatic seizure, GCS score <15, focal neurological deficit, or coagulopathy 1, 2
Level B Recommendation: Non-contrast head CT scan should be considered in patients with head trauma without loss of consciousness or post-traumatic amnesia if they present with focal neurological deficit, vomiting, severe headache, age ≥65 years, signs of base of skull fracture, GCS score <15, coagulopathy, or a dangerous mechanism of injury 1, 2

Direct oral anticoagulants (DOACs) have a lower incidence of intracranial hemorrhage (2.6%) compared to vitamin K antagonists (10.2%), but it is still higher than in non-anticoagulated patients 4, 5
The threshold for performing initial imaging after a mild head trauma in patients with anticoagulants or antiplatelet agents should be very low due to the consequences of not detecting an early hemorrhage 4, 5