Repeat computed tomography head scan is not indicated in trauma patients taking novel anticoagulation: A multicenter study

J Trauma Acute Care Surg. 2020 Aug;89(2):301-310. doi: 10.1097/TA.0000000000002760.


Background: The number of trauma patients on prehospital novel oral anticoagulants (NOACs) is increasing. After an initial negative computed tomography of the head (CTH), practice patterns are variable for obtaining repeat CTH to evaluate for delayed intracranial hemorrhage (ICH-d). However, the risks and outcomes of ICH-d for patients on NOACs are unclear. We hypothesized that, for these patients, the incidence of ICH-d is low, similar to that of warfarin, and when it occurs, it does not result in clinically significant worse outcomes.

Methods: Five level 1 trauma centers in Northern California participated in a retrospective review of anticoagulated trauma patients. Patients were included if their initial CTH was negative. Primary outcomes were incidence of ICH-d, neurosurgical intervention, and death. Patient factors associated with the outcome of ICH-d were determined by multivariable regression.

Results: From 2016 to 2018, 777 patients met the inclusion criteria (NOAC, n = 346; warfarin, n = 431), 54% of whom received a repeat CTH. Delayed intracranial hemorrhage incidence was 2.3% in the NOAC group and 4% in the warfarin group (p = 0.31). No NOAC patient with ICH-d required neurosurgical intervention or died because of their head injury. Two warfarin patients received neurosurgical intervention, and three died from their head injury. Head Abbreviated Injury Scale ≥3 was associated with increased odds of developing ICH-d (adjusted odds ratio, 32.70; p < 0.01).

Conclusion: The incidence of ICH-d in patients taking NOAC is low. In this study, patients on NOACs who developed ICH-d after an initial negative CTH did not need neurosurgical intervention or die from their head injury. Repeat CTH in this patient population does not appear necessary.

Level of evidence: Prognostic/epidemiologic study, level III.Therapeutic, level IV.

Publication types

  • Multicenter Study

MeSH terms

  • Administration, Oral
  • Anticoagulants / adverse effects
  • Anticoagulants / therapeutic use*
  • California / epidemiology
  • Craniocerebral Trauma / complications
  • Craniocerebral Trauma / diagnostic imaging*
  • Humans
  • Incidence
  • Intracranial Hemorrhages / diagnostic imaging*
  • Intracranial Hemorrhages / epidemiology
  • Intracranial Hemorrhages / etiology
  • Practice Patterns, Physicians'
  • Prognosis
  • Retrospective Studies
  • Risk Factors
  • Tomography, X-Ray Computed*
  • Unnecessary Procedures
  • Warfarin / adverse effects
  • Warfarin / therapeutic use


  • Anticoagulants
  • Warfarin