Indications for CT in patients receiving anticoagulation after head trauma

Abstract

Background and purpose: Head CT is frequently ordered for trauma patients who are receiving anticoagulation. However, whether patients with a Glasgow Coma Scale (GCS) score of 15 and normal findings on neurologic examination require CT is still debated. The purpose of our study was to assess the use of cranial CT in patients receiving anticoagulants after head trauma and to establish clinical criteria to identify those in this group who do not need emergency CT.

Methods: We retrospectively reviewed patients receiving heparin or coumadin who had head trauma and who subsequently underwent cranial CT at a level I trauma center within a 4-year period. Patients were evaluated for mechanism of injury, clinical signs and symptoms of head injury, and type and reason for anticoagulation. Prothrombin time, international normalized ratio, partial thromboplastin time, GCS score, age, and head CT results were recorded for each patient.

Results: A total of 89 patients fulfilled the enrollment criteria. Among them, 82 had no evidence of intracranial injury on CT. Seven patients had evidence of intracranial hemorrhage. Patients without hemorrhage had no significant focal neurologic deficits and presented with an average GCS score of 14.8. Patients with intracranial hemorrhage tended to have focal neurologic deficits and presented with an average GCS score of 12.0.

Conclusion: Patients with head injury, normal GCS scores, and no focal neurologic deficits and who are receiving the anticoagulants heparin or coumadin may not necessarily require emergency CT.

Figures

Fig 1.

Images obtained in a 93-year-old woman treated with coumadin for atrial fibrillation. She fell and hit her head at home and presented with nausea, vomiting, a positive left-sided Babinski reflex, and a GCS score of 13. A, Axial nonenhanced CT scan reveals acute right frontoparietal subdural hematoma (black arrows) with a moderate degree of midline shift. Image also shows a small occipital hemorrhagic contusion on the right (white arrow). B, More cephalic CT scan shows a soft tissue hematoma on the left (arrow) consistent with a contrecoup traumatic subdural hematoma. The patient’s anticoagulation status was reversed with vitamin K and fresh frozen plasma. The patient’s clinical condition deteriorated further. She was not a neurosurgical candidate and therefore given conservative care at the request of her family.

Fig 2.

Images obtained in a 75-year-old woman who fell at home and presented with nausea, vomiting, and lethargy. On neurologic examination, she was lethargic but arousable, opening her eyes, responding to voice, and following simple commands. She had a right-sided Babinski sign and a GCS score of 14. Her medical history was significant for atrial fibrillation, for which she was receiving coumadin. Nonenhanced CT scan shows a right cerebellar hemorrhage that extends into the fourth ventricle (arrow). The patient’s coagulation status was reversed with vitamin K and fresh frozen plasma. A few days later, she developed hydrocephalus, which responded to treatment with a ventriculostomy tube. Her condition improved, and she was discharged to a skilled nursing facility.