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Three Part Question

Should [adults with a minor head injury (GCS 15, and no significant symptoms and signs) who are taking antiplatelets agents or novel anticoagulants] be investigated with [CT] to exclude a [therapeutically important abnormality] such as intracranial haemorrhage?

Clinical Scenario

A 60 year old male presents to the Emergency Department with a minor head injury after tripping. He has no associated symptoms with the head injury but is on an anticoagulant. Should his management include a CT head?

Search Strategy

Medline 2014 – Current using Ovid interface [minor head injury mp. OR craniocerebral trauma AND antiplatelet mp. AND anticoagulant mp. OR anticoagulants] Limits English articles only, humans and date limited 2014 to current.
Cochrane database was searched but no relevant reviews were found.
Relevant guidelines and clinical decision tools namely National Institute of Clinical Excellence guidelines.
1 additional paper, a meta analysis was found in the reference of a relevant paper.

Search Outcome

Medline 24 papers, 3 relevant, 7 too specific and therefore not reflective of population in question, 14 irrelevant. The relevant papers are listed below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Savioli et al 2021 Italy	N=1926 patients. Over 18 years with GCS 14 or above. 1443 not receiving antiplatelet therapy or anticoagulant therapy. 483 patients receiving APT therapy	Retrospective single-centre observational study	-Bleeding risk -Cranial neurosurgery -Severity of condition at discharge -Frequency of ED revisits for head trauma in patients receiving APT	-APT not significantly associated with bleeding risk (p>0.05) -APT group had greater need of surgery (1.2% vs 0.4%, p<0.0001) -Clinical condition of those on APT more severe -No difference between groups in ED revisits	-Bleeding predictors chosen based on those felt to be most reliable for a retrospective study rather than clinical implications -Heterogenous population in control group versus treatment group
Nishijima et al 2013 USA	N=982 Receiving warfarin or clopidogrel use (18 or above, gcs 13 or above)	Prospective observational, multicentre study	-Presence of immediate tICH -neurosurgical intervention	-60 patients with immediate tICH -of those 60, 12 received neurosurgical intervention	-Only investigated warfarin or clopidogrel use -Some patients lost to follow-up
Van den Brand et al 2017 Netherlands	10 studies with total of 20, 247 participants	Systematic review. Mix of retrospective and prospective designs	-tICH on CT scan	-Use of APT associated with significant risk of tICH	Not restricted to mild trauma. High level of bias amongst all retrospective studies included. Large heterogeneity in studies including patient population, APT use and outcome definitions. Unable to establish causal relationship between APT use and risk of tICH
Yamada et al 2020 Japan	N=1122. 114 on APT, 49 anticoagulant therapy. 948 with no APT or anticoagulant therapy. 18 years and above	Single centre retrospective	-tICH -dependence or death at discharge	-55 had tICH, 13 using APT and 2 using anticoagulants	Outcomes not clearly defined. Recruitment method not clearly defined. Not clear what inclusion GCS was post injury so potentially not limited to minor head injuries.

Comment(s)

None of the studies identified are definitively able to answer the question posed and only one study investigated a population group who had a GCS of 15. There are conflicting results amongst studies comparing whether use of APT increases the risk of immediate tICH and the classification of ‘mild head injury’ varied amongst studies. From this, none of the studies were able to identify a subset group of patients who are at low risk for abnormalities and the general trend was that those with head injuries on anticoagulants or anti-platelets received CT head imaging despite severity of symptoms. Direct evidence supporting this is limited. Current NICE guidance recommends that if a patient is on APT that the clinician decides on a case-by-case basis on the need for CT. However, the authors note that an update/review is expected of the NICE guidance in 2023.

Clinical Bottom Line

More evidence is required to answer this question definitively. There is no study that can adequately differentiate whether the population group in the proposed question should be managed differently than NICE guidance currently recommends.

References

1. Savioli, G., Ceresa, I.F., Luzzi, S., Lucifero, A.G., Pioli Di Marco, M.S., Manzoni, F., Preda, L., Ricevuti, G., & Bressam, M.A. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicine 57, 357
2. Nishijima, D.K., Offerman, S.R., Ballard, D.W., Vinson, D.R., Chettipally, U.K., Rauchwerger, A.S., Reed, M.E., & Holmes, J.F. Risk of Traumatic Intracranial Hemorrhage in Patients with Head Injury and Preinjury Warfarin or Clopidogrel Use Acad Emerg Med 20 (2), 140-145
3. Van den Brand, C. L., Tolido, T., Rambach, A.H., Hunimk, M.G.M., Patka, P. & Jellema, K. Systematic Review and Meta-Analysis: Is Pre-injury Antiplatelet Therapy Associated with Traumatic Intracranial Hemorrhage? Journal of Neurotrauma 34, 1-7
4. Yamada, C., Hagiwara, S., Ohbuchi, H., & Kassuya, H. Risk of Intracranial Hemorrhage and Short-term outcome in Patients with Minor Head Injury. World Neurosurgery 141, 851-857