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Three Part Question

Do [adults with a mild head injury] [on warfarin] benefit from [INR reversal]

Clinical Scenario

A 78 year old man on warfarin for AF presents to the ED with a head injury following a mechanical fall. There was no LOC, nausea or vomiting, amnesia or visual disturbances and neurological examination was normal. He did however sustain a laceration to his occiput, which required suturing. Despite not fulfilling NICE criteria he underwent a CT head, which was unremarkable besides an old infarct.

The gentleman was admitted for observation and 10hrs later dropped his GCS to 4/15. Repeat CT demonstrated a large subdural haematoma. He subsequently died 14hrs later.

In hindsight, should his INR have been reversed regardless of its value to help prevent delayed bleeding?

Search Strategy

Medline 2001-2011 using OVID interface.

(("craniocerebral trauma"[MeSH Terms] OR ("craniocerebral"[All Fields] AND "trauma"[All Fields]) OR "craniocerebral trauma"[All Fields] OR ("head"[All Fields] AND "injury"[All Fields]) OR "head injury"[All Fields]) AND ("warfarin"[MeSH Terms] OR "warfarin"[All Fields])) AND ("2001/07/07"[PDat] : "2011/07/04"[PDat])

Search Outcome

No papers were found to address this issue.

Comment(s)

It is well known that patients with a coagulopathy such as those on warfarin who have an intracranial haemorrhage benefit from rapid INR reversal. There is a theoretical benefit of decreasing the risk of delayed intracranial haemorrhage by reversing the INR of patients on warfarin after sustaining a relatively 'minor' head injury and having a normal CT head. This theoretical benefit will have to be balanced against the reason for anticoagulation.

Clinical Bottom Line

Further work is needed to address this question. Clinicians should have a low threshold for obtaining a CT head on these type of patients- solely following NICE will miss some intracranial haemorrhages. A period of close observation for these patients is also important.