Do patients on Direct Oral Anticoagulants (DOACs) require repeat imaging and a period of observation after a head injury with an initial negative CT?

Statement reviewed and approved by AAEM Board of Directors. (4/8/2021)

Summary Recommendation:
There is substantial clinical uncertainty regarding the management of head injured patients taking DOACs for delayed intracranial hemorrhage (ICH) as there are no high-quality studies evaluating this question. DOACs have been generally shown to have a reduced rate of mortality, hemorrhagic stroke, and intracranial hemorrhage compared with vitamin K antagonists (VKAs). While there is substantial evidence showing that delayed ICH after head injury is very rare with VKAs this cannot be directly extrapolated to patients on DOACs.(1) Thus, in the absence of high-quality studies evaluating delayed ICH with DOACs after head injury, the clinician should carefully evaluate the risks and benefits of immediate discharge or a period of observation and repeat CT.

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Reference and Literature Grading (PDF)