Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED).


      This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI.


      A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED.


      Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients.


      Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.


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        • Chan N
        • Sobieraj-Teague M
        • Eikelboom JW.
        Direct oral anticoagulants: evidence and unresolved issues.
        Lancet. 2020; 396: 1767-1776
        • van Es N
        • Coppens M
        • Schulman S
        • Middeldrop S
        • Büller H.R.
        Direct oral anticoagulants compared with vitamin K antagonists for acute venous thromboembolism: evidence from phase 3 trials.
        Blood. 2014; 124: 1968-1975
        • Scaglione F.
        New oral anticoagulants: comparative pharmacology with vitamin K antagonists.
        Clin Pharmacokinet. 2013; 52: 69-82
        • Cheng JW
        • Barillari G.
        Non-vitamin K antagonist oral anticoagulants in cardiovascular disease management: evidence and unanswered questions.
        J Clin Pharm Ther. 2014; 39: 118-135
        • Anand SS
        • Bosch J
        • Eikelboom JW
        • et al.
        Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial.
        Lancet. 2018; 391: 219-229
        • Tsilimigras DI
        • Moris D
        • Karaolanis G
        • Kakkos SK
        • Filis K
        • Sigala F.
        Rivaroxaban versus clopidogrel for peripheral artery disease: a clinico-economic approach of the COMPASS trial.
        Curr Pharm Des. 2018; 24: 4516-4517
        • Fuller G
        • Sabir L
        • Evans R
        • Bradbury R
        • Kuczawski M
        • Mason SM.
        Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis.
        Emerg Med J. 2020; 37: 666-673
        • Turcato G
        • Zaboli A
        • Zannoni M
        • et al.
        Risk factors associated with intracranial bleeding and neurosurgery in patients with mild traumatic brain injury who are receiving direct oral anticoagulants.
        Am J Emerg Med. 2021; 43: 180-185
        • Savadei F
        • Teasdale G
        • Merry G.
        Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management.
        J Neurotrauma. 2001; 18: 657-664
        • Agenzia Nazionale per i Servizi Sanitari Regionali
        Trattamento del Trauma Cranico minore e severo.
        Linee Guida Nazionali di Riferimento, 2007
      1. National Institute for Health and Care Excellence. Head Injury: Assessment and Early Management (NICE guideline). National Institute for Health and Care Excellence; 2019.

        • Stiell IG
        • Clement CM
        • Rowe BH
        • et al.
        Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury.
        JAMA. 2005; 294: 1511-1518
        • Haydel MJ
        • Preston CA
        • Mills TJ
        • Luber S
        • Blaudeau E
        • DeBlieux PM.
        Indications for computed tomography in patients with minor head injury.
        N Engl J Med. 2000; 343: 100-105
        • Yates D
        • Aktar R
        • Hill J.
        Assessment, investigation, and early management of head injury: summary of NICE guidance.
        BMJ. 2007; 335: 719-720
        • Cohn B
        • Keim SM
        • Sanders AB.
        Can anticoagulated patients be discharged home safely from the emergency department after minor head injury?.
        J Emerg Med. 2014; 46: 410-417
        • Ziegler A
        • Vens M.
        Generalized estimating equations. Notes on the choice of the working correlation matrix.
        Methods Inf Med. 2010; 49: 421-432
        • Capogrosso P
        • Vickers AJ.
        A systematic review of the literature demonstrates some errors in the use of decision curve analysis but generally correct interpretation of findings.
        Med Decis Making. 2019; 39: 493-498
        • Vickers AJ
        • van Calster B
        • Steyerberg EW.
        A simple, step-by-step guide to interpreting decision curve analysis.
        Diagn Progn Res. 2019; : 3-18
        • Vickers AJ
        • Elkin EB.
        Decision curve analysis: a novel method for evaluating prediction models.
        Med Decis Making. 2006; 26: 565-574
        • Cipriano A
        • Park N
        • Pecori A
        • et al.
        Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs.
        Intern Emerg Med. 2021; 16: 1061-1070
        • Fuller GW
        • Evans R
        • Preston L
        • Woods HB
        • Mason S.
        Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review.
        Ann Emerg Med. 2019; 73: 66-75
        • Chenoweth JA
        • Johnson MA
        • Shook L
        • Sutter ME
        • Nishijima DK
        • Holmes JF.
        Prevalence of intracranial hemorrhage after blunt head trauma in patients on pre-injury dabigatran.
        West J Emerg Med. 2017; 18: 794-799
        • Savioli G
        • Ceresa IF
        • Luzzi S
        • et al.
        Rates of intracranial hemorrhage in mild head trauma patients presenting to emergency department and their management: a comparison of direct oral anticoagulant drugs with vitamin K antagonists.
        Medicina (Kaunas). 2020; 56: 308
        • Uccella L
        • Zoia C
        • Perlasca F
        • Bongetta D
        • Codecà R
        • Gaetani P.
        Mild traumatic brain injury in patients on long-term anticoagulation therapy: do they really need repeated head CT scan?.
        World Neurosurg. 2016; 93: 100-103
        • Probst MA
        • Gupta M
        • Hendey GW
        • et al.
        Prevalence of intracranial injury in adult patients with blunt head trauma with and without anticoagulant or antiplatelet use.
        Ann Emerg Med. 2020; 75: 354-364
        • Vaniyapong T
        • Patumanond J
        • Ratanalert S
        • Limpastan K.
        Clinical indicators for traumatic intracranial findings in mild traumatic brain injury patients.
        Surg Neurol Int. 2019; 10: 64
        • Mason S
        • Kuczawski M
        • Teare MD
        • et al.
        AHEAD study: an observational study of the management of anticoagulated patients who suffer head injury.
        BMJ Open. 2017; 7e014324
        • Hickey S
        • Hickman ZL
        • Conway J
        • Giwa A.
        The effect of direct oral anti-coagulants on delayed traumatic intracranial hemorrhage after mild traumatic brain injury: a systematic review.
        J Emerg Med. 2021; 60: 321-330
        • Chauny J
        • Marquis M
        • Bernard F
        • et al.
        Risk of delayed intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: systematic review and meta-analysis.
        J Emerg Med. 2016; 51: 519-528
        • Giustozzi M
        • Franco L
        • Vedovati MC
        • Becattini C
        • Agnelli G.
        Safety of direct oral anticoagulants versus traditional anticoagulants in venous thromboembolism.
        J Thromb Thrombolysis. 2019; 48: 439-453
        • Conway SE
        • Hwang AY
        • Ponte CD
        • Gums JG.
        Laboratory and clinical monitoring of direct acting oral anticoagulants: what clinicians need to know.
        Pharmacotherapy. 2017; 37: 236-248
        • Scantling D
        • Fischer C
        • Gruner R
        • Teichman A
        • McCracken B
        • Eakins J.
        The role of delayed head CT in evaluation of elderly blunt head trauma victims taking antithrombotic therapy.
        Eur J Trauma Emerg Surg. 2017; 43: 741-746
        • Zhang F
        • Li H
        • Qian J
        • et al.
        Hyperglycemia predicts blend sign in patients with intracerebral hemorrhage.
        Med Sci Monit. 2018; 24: 6237-6244
        • Weber J
        • Olyaei A
        • Shatzel J.
        The efficacy and safety of direct oral anticoagulants in patients with chronic renal insufficiency: a review of the literature.
        Eur J Haematol. 2019; 102: 312-318
        • Steuber TD
        • Howard ML
        • Nisly SA.
        Direct oral anticoagulants in chronic liver disease.
        Ann Pharmacother. 2019; 53: 1042-1049
        • Vickers AJ
        • Cronin AM
        • Elkin EB
        • Gonen M.
        Extensions to decision curve analysis, a novel method for evaluating diagnostic tests, prediction models and molecular markers.
        BMC Med Inform Decis Mak. 2008; 8: 53

      Linked Article

      • Wrong Cohort to Reduce “Unnecessary” CT Imaging
        Journal of Emergency Medicine
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          We commend the authors on studying a robust database of over 1000 patients taking direct oral anticoagulants (DOACs) who sustained minor head trauma in their article in the current journal entitled “Analysis of clinical and laboratory risk factors of post-traumatic intracranial hemorrhage in patients on DOACs with mild traumatic brain injury: an observational multicenter cohort”. The methodology was sound. We agree with excluding patients who arrived 48 hours after their trauma (asymptomatic after 48 hours would not require head imaging), those that took their last dose of DOAC 24 hours prior to the head trauma (need for imaging does not need to factor in the risk of anticoagulation), and those that arrive with focal deficits (immediate imaging required).
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