Repeat CT for anticoagulated patients with mild TBI: Necessary or Pointless?
The Article: Mild brain injury and anticoagulants Campiglio, L. et al. Neurol Clin Pract. 2017 Aug;7(4):296-305.
The Big Take-away: Repeat head CT for patients with mild brain injuries who are taking anticoagulation is unnecessary and expensive.
So, a patient arrives in your emergency room saying she had a fall at home. Not a particularly bad fall, but a fall nonetheless. She says she was walking into the bathroom and slipped on some water. She reached for the sink, but couldn’t grab it and down she went. It just wasn’t her day. She can’t remember if she lost consciousness or not, but her daughter, who thankfully was home that day, was by her side in a matter of seconds after she heard a loud ‘thud’ above her.
“She seemed a little out of it at first,” the daughter reports. “But over the next 5-10 minutes, she generally came around and now she seems to be doing much better.” You take a look at the patient, who points to a small bump on her forehead and says she has a headache. She also happens to be on anticoagulation, but can’t remember why.
Now the first part of the work-up for this patient is pretty straight forward. You’ll order a head CT and try to rule-out reasons she might have fallen. But what do you do when your initial work-up is negative and the head CT shows you nothing but the normal wear and tear of an elderly brain. Do you admit? Do you observe? Do you order repeat imaging? This last question was the crux of the problem Campiglio and the rest of her buddies were trying to answer. What’s the best approach in terms of repeat imaging for patients taking anticoagulation who present with mild brain injuries?
Of course, before we dive to far down this rabbit hole, it helps to define what exactly constitutes a mild traumatic brain injury (TBI). In the paper, a Mild TBI represents patients with a GCS 13 or greater; loss of consciousness for less than 30 minutes and post traumatic amnesia that lasts less than 24 hours. The study then looks at patients older than 18 with blunt head trauma who presented with the above criteria. All patients received an initial head CT (CT-1) and if negative were admitted for a 48-period of observation at the end of which they received a second head CT (CT-2).
Of the initial 344 patients who met the researchers criteria, 284 had a negative CT-1. Of the 284, only four subsequently had a positive CT-2 and of those four, none demonstrated a change in mental status or required neurosurgical intervention. The only complaint noted was a mild headache, which isn’t horribly surprising for a person who just got hit it the head. As a result, the paper concludes repeat imaging after 48-hours is not justified as it doesn’t alter clinical management in a large majority of patients with mild TBI. What it does do is expose patients to more radiation and it’s expensive. The paper quotes a price of $8,152 for a 48-hour hospital stay.
The study itself was a retrospective review, completed at a single center, so people will certainly debate about whether the results are truly generalizable. The paper also acknowledges that it may suffer from selection bias, in that its population was generally older and mainly had falls from standing, which may be a reason the occurrence of head bleeds tended to skew lower (1.4%) than the range in the published literature (0.6% to 6%). In papers where motor vehicle accidents made up a higher percentage of the trauma studied, occurrence of head bleeds moved toward the 6% mark. Regardless, that doesn’t dilute the overall questions the researchers are asking about the utility of blanket repeat scanning without some change in clinical condition.
So what do you think? Does this paper make a good enough argument for you to change your practice? Are you going to start sending your anticoagulated mild TBIs out the door after 24-hours and one negative CTH? Maybe a better question is whether you’re able to change your practice even if you wanted to? That was the general idea around the Temple Journal Club. Though most felt a second CT is probably unwarranted, none, understandably, were willing to act against a hospital policy recommending one be ordered. That is probably where the true impact of this research will be felt. Now that good data is starting to suggest that follow-up head CTs are not particularly helpful, (not to mention expensive) maybe a move can be made to start re-writing hospital policy so practitioners have more leeway in how they choose to dispo anticoagulated patients presenting with head trauma. Certainly, no one is suggesting we throw out the initial head CT or even a period of observation, but how long that observation lasts and what testing needs to be ordered prior to discharge is ripe for debate.
Anyway, I’d love to hear your thoughts. Feel free to drop a note in the comments below or shoot me an email at firstname.lastname@example.org.