Delayed Intracranial Hemorrhage in Patients Taking Warfarin with Head Trauma

CONTEXT: Patients presenting to the Emergency Department after a minor head injury have been shown to have a higher incidence of delayed spontaneous intracranial bleed, even with an initial negative CT. Some institutions have initiated a protocol of 24-hour observation followed by repeat head CT scan the next day. At the authors’ institution, a 24-hour observation protocol was adopted in January 2012. The authors sought to evaluate the utility of this protocol given the apparently limited amount of data to support such a practice. METHODS: A 12-month prospective observational study conducted at a community hospital evaluating a 24-month observation protocol for patients presenting after a minor head injury. During this study period, a sample of minor head injury patients were identified and followed through their hospital course. CT scan results were also compiled, and patient charts were reviewed at 30 days for any return visits or post-injury complications. RESULTS: A total of 51 patients were enrolled during the study period. Of those patients receiving a repeat head CT, none showed any evidence of a new or worsening intracranial bleed, with all patients discharged safely from the hospital. At 30 days, patients’ charts were reviewed to examine whether any patients had returned to the hospital for any reason. No sample patients returned to the hospital within the 30-day review period. CONCLUSION: Similar to the results of the retrospective chart review, no sample patients with minor head injuries showed any evidence of a subsequent delayed intracranial bleed during the 12-month study period. Our study results suggest that 24-hour observation protocols with costly repeat CT head scans may not be useful in the management of most head trauma patients. Patients may be better served to be discharged home with education including signs of symptoms of a worsening bleed (i.e., confusion, worsening headaches and not feeling right) that actually warrant a return to the hospital.