Key result
DOACs show no difference in delayed ICH risk versus VKAs after mild traumatic brain injury.
Why the study?
The utility of routine repeated CT scans to detect delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury and negative initial CT is controversial.
Does the type of oral anticoagulant (DOAC vs VKA) affect the incidence of delayed intracranial hemorrhage in patients with mild traumatic brain injury and an initially negative CT scan?
Cohort (n=1,596)
Yes
Does the type of oral anticoagulant (DOAC vs VKA) affect the incidence of delayed intracranial hemorrhage in patients with mild traumatic brain injury and an initially negative CT scan?
Odds Ratio: 1.8 (95% CI 0.9–3.6)
Absolute Event Rate: 2.6% vs 1.8%
p-value: p=0.122
Delayed intracranial hemorrhage is uncommon in anticoagulated patients with mild traumatic brain injury and an initially negative CT, suggesting routine repeat CT scanning may be unnecessary without high-risk clinical features.
Low delayed ICH rates may support selective repeat CT; leaves open need for prospective validation of anticoagulant class effects.
BACKGROUND: Anticoagulated patients with mild traumatic brain injury (mTBI) and a negative cerebral CT on admission, commonly undergo a repeated CT scan after observation in the emergency department (ED) to detect delayed intracranial hemorrhage (ICH). However, the utility of this practice is controversial, with recent evidence suggesting that the risk of delayed ICH in these patients is low. This study aims to evaluate incidence, outcomes, and risk factors of delayed ICH in patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) presenting to the ED with mTBI. METHODS: A multicenter, observational, retrospective cohort study was conducted in the EDs of three hospitals in Northern Italy, from January 2017 to December 2021. All consecutive adult patients on DOACs or VKAs therapy, admitted for a mTBI, who underwent a second CT scan after 12-24 h from a negative first one, were enrolled. RESULTS: A total of 1596 anticoagulated patients were enrolled, 869 (54%) on DOACs and 727 (46%) on VKAs therapy. The median age was 84 [79-88] and 56% of patients were females. The incidence of delayed ICH was 1.8% (95% CI: 1.1-3.0%; 14/869 patients) for DOACs, and 2.6% (95% CI: 1.6-4.1%; 19/727 patients) for VKAs patients, with no cases requiring neurosurgical intervention. Vomiting after head injury and the onset of new symptoms during observation were associated with a higher risk of delayed bleeding (OR 4.8; 95% CI: 1.4-16.5, and OR 4.7; 95% CI 1.2-23.7, respectively). At a 30-day follow-up, 2% of patients had a new ED admission related to their previous mTBI, with no significant difference between the groups. CONCLUSIONS: Delayed ICH is uncommon among anticoagulated patients with mTBI and has minimal impact on their outcome. Routine performance of a second CT scan may be unnecessary and may be considered only in presence of high-risk clinical risk factors or signs of deterioration.
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Capsoni et al. (2025) conducted a cohort in Mild traumatic brain injury (mTBI) (n=1,596). Vitamin K antagonists (VKAs) vs. Direct oral anticoagulants (DOACs) was evaluated on Incidence of delayed intracranial hemorrhage (ICH) at follow-up CT scan (OR 1.8, 95% CI 0.9-3.6, p=0.122). Delayed intracranial hemorrhage occurred in only 2.6% of patients on VKAs and 1.8% on DOACs following mild traumatic brain injury, with no significant difference between the groups (OR 1.8).
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