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Risk of significant traumatic brain injury in adults with minor head injury taking direct oral anticoagulants: a cohort study and updated meta-analysis
  1. Gordon Fuller1,
  2. Lisa Sabir1,
  3. Rachel Evans1,
  4. Daniel Bradbury2,
  5. Maxine Kuczawski1,
  6. Suzanne M Mason1
  1. 1Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield, UK
  2. 2Emergency Department, Northern General Hospital, Sheffield Teaching Hospitals, Sheffield, UK
  1. Correspondence to Dr Gordon Fuller, Center for Urgent and Emergency Care Research, School of Health and Related Research, The University of Sheffield, Sheffield S10 2TG, UK; g.fuller{at}


Background Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group.

Methods An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies.

Results 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%).

Conclusions The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.

  • trauma
  • head
  • research
  • clinical
  • imaging
  • CT/MRI
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  • Contributors All authors made substantial contributions to the conception and design (GF, RE, LS, DB, MK, SMM), acquisition of the data (RE, LS, DB) or analysis and interpretation (GF, SMM). GF drafted the article and all other authors revised it critically for important intellectual content. SMM is the guarantor. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Ethics approval The study received approval from the Sheffield Teaching Hospitals Ethics committee (ethics approval reference STH20253). A pre-specified protocol was developed prior to analysis.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data requests should be submitted to the corresponding author for consideration. Access to anonymised data may be granted following review.

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