• Current ACEP guidelines recommend to consider neuroimaging after blunt head trauma in patients with coagulopathy.
• However, they do not provide guidance specific to antiplatelet vs. anticoagulant medications.
• A recent multicenter prospective observational study of 9070 patients where 14.6% were receiving antiplatelet medications or warfarin found the relative risk of significant intracranial injury was:
  • 1.29 (95% CI 0.88-1.87) for aspirin alone
  • 0.75 (95% CI 0.24-2.30) for clopidogrel alone
  • 1.88 (95% CI 1.28-2.75) for warfarin alone
  • 2.88 (95% CI 1.53-5.42) for aspirin and clopidogrel in combination
• Significant intracranial injury did not include isolated linear or basilar skull fractures or single small cerebral contusions <2 cm in diameter.
• The study only included patients who underwent neuroimaging, though the researchers also looked at 368 consecutive patients with blunt head injury who did not receive neuroimaging and did not find any missed injuries at 3-month follow-up.

Bottom Line: Patients on warfarin or a combination of aspirin and clopidogrel have increased risk of significant intracranial injury after blunt head trauma.  Aspirin or clopidogrel monotherapy do not appear to be risk factors.

References

• ACEP clinical policy: Neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med. 2008;52:714-748.
• Probst MA, Gupta M, Handey GW, et al. Prevalence of intracranial injury in adult patients with blunt head trauma with and without anticoagulant or antiplatelet use. Ann Emerg Med. 2020;75(3):354-364.

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