Is a Repeat Head CT Scan Necessary After an Initial Negative Scan in Head Trauma Patients on DOAC Therapy in the Emergency Department?

Background: Head trauma in patients receiving direct oral anticoagulants (DOACs) presents a clinical dilemma because of concern for delayed intracranial hemorrhage (ICH). Although some emergency departments (EDs) routinely perform repeat head CT after an initially negative scan, the clinical value of this practice remains uncertain. Methods: We conducted a retrospective observational cohort study at Hadassah Mount Scopus University Hospital Emergency Department (ED), a level 3 trauma center with approximately 70,000 visits per year, spanning January 2019 to December 2022. Adult patients receiving DOAC therapy who sustained blunt head trauma and underwent both an initial and repeat head CT according to institutional protocol were included. Demographic characteristics, clinical presentation, type of DOAC, and CT findings were recorded. Exclusion criteria included: penetrating trauma, multi trauma, identified intracranial hemorrhage on the first scan, age < 18 years, and pregnancy status. Results: A total of 421 patients met the inclusion criteria. The mean age was 80.1 years, and 236 patients (56%) were female. Apixaban was the most prescribed DOAC (364 patients, 86%), followed by rivaroxaban (39 patients, 9.5%) and dabigatran (18 patients, 4.5%). Glasgow Coma Scale was 15 in 399 patients (94.7%) on presentation. Five patients (1.2%,95% CI: 0.5–2.8%) had delayed ICH on repeat CT after an initially negative scan. All five patients were older than 75 years and had visible evidence of blunt head trauma, and one required neurosurgical intervention. Conclusions: Delayed ICH after blunt head trauma in DOAC-treated patients with an initially negative CT was uncommon. These findings support that routine repeat CT scanning for all patients may be unnecessary, and a more focused subsequent CT scan strategy could ultimately optimize hospital resources without compromising patient safety—specifically among elderly patients, those with a low GCS, or showing evidence of trauma. Future research should also evaluate whether emerging blood-based biomarkers can help identify DOAC-treated patients at risk for delayed intracranial hemorrhage despite an initially negative CT scan.