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Delayed Intracranial Hemorrhage after Blunt Head Trauma while on Direct Oral Anticoagulant: Systematic Review and Meta-Analysis. J Am Coll Surg 2021 Jun;232(6):1007-1016.e5



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Scopus ID

2-s2.0-85103329670 (requires institutional sign-in at Scopus site)   10 Citations


INTRODUCTION: Delayed intracranial hemorrhage (ICH) after a negative initial head cat scan (CT) is a recognized complication after blunt trauma but the risk of this condition is unknown. Due to theoretical increased risk in patients on direct oral anticoagulants (DOACs) and inability to monitor degree of anticoagulation, there is a lack of consensus regarding need for additional observation or routine repeat head CT. We hypothesized that patients on DOACs would have a low risk of delayed ICH after blunt head trauma.

METHODS: In June 2020, an electronic literature search of MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library was performed by a medical librarian (TH) using a combination of keywords and subject headings. Databases were searched from inception through June 2020. Included studies reported outcome data on trauma patients greater than 18 years old who were taking anticoagulants and were observed after initial normal head CT. A meta-analysis was performed using a random effects model. The Newcastle-Ottawa Scale (NOS) was utilized for assessing the quality of nonrandomized studies in meta-analyses.

RESULTS: Our electronic search returned 5719 papers and after removal of duplications, 72 underwent full review, and 12 met final inclusion/exclusion criteria. Four thousand eight hundred ninety one of 5289 (92%) patients suffered a ground level fall. Four studies reported routine repeat CT scans on all patients while the remaining only repeated CT scans for symptoms. Overall, 5289 patients were studied and 1263 (23.9%) were on a DOAC. Sixty-nine patients suffered delayed intracranial hemorrhage, 25 on DOAC and 44 on warfarin. The pooled weighted proportion for delayed ICH on DOAC was 2.43% (95% CI, 1.31 – 3.88%) compared to 2.31% (95% CI, 1.26 – 3.66%) on warfarin. Eighty six percent of patients (59/69) who suffered delayed ICH had no clinical consequences while 0.16% (2/1263) of those on DOAC and 0.48% (8/1788) of those on warfarin died from complications following delayed ICH. The overall crude risk of death from delayed ICH while on DOAC or Warfarin was 0.36% (11/3051).

CONCLUSIONS: The risk of delayed ICH following low energy blunt head trauma for patients on DOACs is low, and the risk of a clinically significant bleed is even lower. The practice of routinely observing or systematically repeating head CT in patients on DOACs after low energy blunt head trauma with initially negative head CT may not be warranted.

Author List

Puzio TJ, Murphy PB, Kregel HR, Ellis RC, Holder T, Wandling MW, Wade CE, Kao LS, McNutt MK, Harvin JA


Patrick Murphy MD Assistant Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Administration, Oral
Atrial Fibrillation
Head Injuries, Closed
Intracranial Hemorrhages
Risk Assessment
Time Factors
Tomography, X-Ray Computed
Venous Thromboembolism