No delayed intracranial hemorrhage in head injury patients on oral anticoagulants and with normal CT: a retrospective study of 215 patients.

BACKGROUND: The current Scandinavian Neurotrauma Committee’s (SNC) guidelines mandate 24-hour hospital observation for head injury patients on anticoagulation therapy even with a normal head CT to detect delayed hemorrhages. However, emerging evidence suggests the incidence of delayed intracranial hematoma in this context is very low. A new protocol was developed at Sørlandet Hospital Kristiansand allowing for immediate discharge of patients on anticoagulation therapy with Glasgow Coma Scale (GCS) 14–15 and normal head CT. This study evaluates the management, incidence of delayed intracranial hemorrhage and re-contact rates in anticoagulated patients with a head injury and normal CT. METHODS: A retrospective review of all patients who sustained a head injury and underwent a CT scanning at Sørlandet Hospital Kristiansand, Norway from April 1, 2024, to December 12, 2025, was performed. Patients were included in the study if they were taking oral anticoagulation of any type and had a normal CT scanning of the head. Demographic data, mechanism of injury, GCS on admission, discharge or admission decisions, re-contact with the hospital, neurosurgical intervention and mortality were registered. Delayed intracranial hemorrhage was defined as any intracranial hematoma not evident on the initial CT but detected on a subsequent CT scan. Clinically relevant delayed hemorrhage was considered as a hematoma requiring re-admission, neurosurgical intervention, or causing death. RESULTS: A total of 795 patients underwent head CT with a median age of 74 years (3–99 years). Of these, 232 patients were taking oral anticoagulation of which 215 had normal CT scans and composed our study group. Median age in the study group was 83 years (33–97 years). GCS on admission was 14–15 in 223/232 (96.1%) of patients. None developed delayed intracranial hemorrhage during observation or follow-up. No patients were transferred for neurosurgical intervention or experienced any clinically significant deterioration due to delayed hemorrhage. CONCLUSION: In this cohort of anticoagulated head injury patients with normal head CT, the incidence of delayed intracranial hemorrhage was zero. Our findings suggest that routine 24-hour observation of all such patients may offer limited benefits, and that a more selective management approach could be justified.