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Three Part Question

Patients on [warfarin] with a [minor head injury] are at greater risk of [intracranial hemorrhage]

Clinical Scenario

A 64 year old lady on long term warfarin for atrial fibrillation attended the A&E department following a fall. She has sustained a frontal head laceration with very brief loss of consciousness. She has a GSC score of 15 with no neurological symptoms. You wonder if patients on warfarin and a minor head injury are at risk of intracranial injury and as a result if they all require admission for neuro-observation

Search Strategy

MEDLINE 1966 - 07/02 using the OVID interface
[exp. warfarin or warfarinised exp. anticoagulants.mp.] AND exp. craniocerebral trauma injuries.mp OR minor head injury.mp OR exp. head injury AND [intracranial haemorrhage, traumatic or exp brain injuries or exp haemorrhage or intracranial bleeding.mp or intracranial haemorrhages.mp] human and english

Search Outcome

Altogether 66 papers were found, of which two were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Li and Levine 2001 USA	144 patients on warfarin with minor head trauma, who underwent CT scanning	Retrospective study	Incidence of abnormalities on CT scanning	10 CT scans had 'clinically important injuries'. -6 parenchymal injuries. -2 subdural haematoma. -1 subarachnoid haemorrhage. -1 acute ischaemic stroke.	Retrospective Minor HIs who did not undergo CT scan not included. CT scan reported as abnormal for non-intracranial haemorrhagic injuries
Garra 1999 USA	65 pts on long-term warfarin with minor HI	Retrospective study	Incidence of abnormalities on CT scanning and telephone follow-up	39 pts had a normal CT scan. 26 pts who had no CT scan had telephone FU, revealing no complications.	Retrospective Not every patient was CT scanned

Comment(s)

Current management decisions regarding admission are based on the assumption of coagulated patients with minor head injury are at greater risk of intracranial haemorrhage. Despite this, there are no well designed studies documenting a risk of intracranial injuries in this group of patients. The subject requires prospective study.

Clinical Bottom Line

In the absence of good quality evidence the current '' safe'' practice of admitting coagulated patients who have sustained a minor HI should for observation. CT scan should be performed early if there is any or development of neurological symptoms.

References

1. Li J. Brown J. Levine M. Mild head injury, anticoagulants, and risk of intracranial injury. [Letter]. Lancet 357(9258):771-2, 2001 Mar 10.
2. Garra G. Nashed AH. Capobianco L. Minor head trauma in anticoagulated patients. Academic Emergency Medicine 6(2):121-4, 1999 Feb.