Modified HAS-BLED score for predicting delayed intracranial hemorrhage in DOAC-treated geriatric head trauma

BACKGROUND Geriatric patients receiving direct oral anticoagulants (DOACs) are at risk of delayed intracranial hemorrhage (DICH) after head trauma despite an initially normal cranial CT. Clear guidance on observation and repeat imaging is lacking. This study evaluated the clinical utility of the modified HAS-BLED score for predicting DICH and informing follow-up imaging decisions. METHODS This retrospective cohort study included 472 patients aged ≥65 years who were receiving DOACs, presented with blunt head trauma, and had a normal initial cranial CT. Clinical and laboratory data were extracted from electronic records. The modified HAS-BLED score was calculated for each patient. The primary outcome was DICH detected on follow-up imaging. Multivariable logistic regression and ROC analyses were performed. RESULTS Delayed intracranial hemorrhage (DICH) occurred in 22 patients (4.7%). Patients with DICH were older and had lower eGFR and higher INR levels in univariate analysis. The modified HAS-BLED score was significantly higher in patients who developed DICH and remained an independent predictor in multivariable analysis. ROC analysis demonstrated good discriminative performance, with an AUC of 0.878 (95% CI 0.806-0.931), and a cut-off value of ≥3 provided a sensitivity of 90.9% and a specificity of 75.3% with a high negative predictive value for identifying low-risk patients. CONCLUSION The modified HAS-BLED score is a strong independent predictor of delayed intracranial hemorrhage in geriatric DOAC users with head trauma. It may serve as a practical tool for early risk stratification, supporting selective rather than routine repeat imaging.