Risk of immediate and delayed intracranial hemorrhage after minor head trauma: DOACs vs warfarin vs no anticoagulation.

BACKGROUND

Minor head trauma frequently prompts emergency department (ED) evaluation and raises concern for intracranial hemorrhage (ICH) in anticoagulated patients. Comparative data on outcomes among patients receiving direct oral anticoagulants (DOACs), warfarin, or no anticoagulation remain limited.

METHODS

We conducted a multicenter retrospective cohort study using the TriNetX Global Collaborative Network (2014-2024). Adults (≥18 years) presenting to the ED with minor head trauma who underwent head CT were included; patients with major or penetrating trauma or recent neurosurgery were excluded. Patients were classified as receiving a DOAC (apixaban, rivaroxaban, dabigatran, edoxaban), warfarin, or no anticoagulant within 7 days prior to presentation. Three pairwise propensity-score-matched comparisons were performed. The primary outcome was delayed ICH within 30 days after an initially negative head CT. Secondary outcomes included immediate ICH, 30-day mortality, neurosurgical intervention, seizure, transfusion, and ED recidivism.

RESULTS

Among 1,819,568 encounters, 34,307 (1.9%) patients were on DOACs, 14,541 (0.8%) on warfarin, and 1,770,720 (97.3%) on neither. After matching, DOAC use was associated with lower immediate ICH (3.8% vs 5.0%; OR 0.74, 95% CI 0.67-0.83), delayed ICH (2.6% vs 3.3%; OR 0.79, 95% CI 0.69-0.91), and 30-day mortality (3.5% vs 4.4%; OR 0.80, 95% CI 0.71-0.90) compared with warfarin. Compared with no anticoagulation, DOAC use was not associated with differences in ICH or mortality.

CONCLUSION

In adults with minor head trauma, DOAC use was associated with a more favorable safety profile than warfarin.