{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T09:10:07Z","timestamp":1790327407090,"version":"4.1.0"},"reference-count":27,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T00:00:00Z","timestamp":1790294400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: Head trauma in patients receiving direct oral anticoagulants (DOACs) presents a clinical dilemma because of concern for delayed intracranial hemorrhage (ICH). Although some emergency departments (EDs) routinely perform repeat head CT after an initially negative scan, the clinical value of this practice remains uncertain. Methods: We conducted a retrospective observational cohort study at Hadassah Mount Scopus University Hospital Emergency Department (ED), a level 3 trauma center with approximately 70,000 visits per year, spanning January 2019 to December 2022. Adult patients receiving DOAC therapy who sustained blunt head trauma and underwent both an initial and repeat head CT according to institutional protocol were included. Demographic characteristics, clinical presentation, type of DOAC, and CT findings were recorded. Exclusion criteria included: penetrating trauma, multi trauma, identified intracranial hemorrhage on the first scan, age &lt; 18 years, and pregnancy status. Results: A total of 421 patients met the inclusion criteria. The mean age was 80.1 years, and 236 patients (56%) were female. Apixaban was the most prescribed DOAC (364 patients, 86%), followed by rivaroxaban (39 patients, 9.5%) and dabigatran (18 patients, 4.5%). Glasgow Coma Scale was 15 in 399 patients (94.7%) on presentation. Five patients (1.2%,95% CI: 0.5\u20132.8%) had delayed ICH on repeat CT after an initially negative scan. All five patients were older than 75 years and had visible evidence of blunt head trauma, and one required neurosurgical intervention. Conclusions: Delayed ICH after blunt head trauma in DOAC-treated patients with an initially negative CT was uncommon. These findings support that routine repeat CT scanning for all patients may be unnecessary, and a more focused subsequent CT scan strategy could ultimately optimize hospital resources without compromising patient safety\u2014specifically among elderly patients, those with a low GCS, or showing evidence of trauma. Future research should also evaluate whether emerging blood-based biomarkers can help identify DOAC-treated patients at risk for delayed intracranial hemorrhage despite an initially negative CT scan.<\/jats:p>","DOI":"10.3390\/jcm15197465","type":"journal-article","created":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T08:09:02Z","timestamp":1790323742000},"page":"7465","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Is a Repeat Head CT Scan Necessary After an Initial Negative Scan in Head Trauma Patients on DOAC Therapy in the Emergency Department?"],"prefix":"10.3390","volume":"15","author":[{"given":"Emad","family":"Talhami","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Hadassah Mount Scopus Hospital, Jerusalem 91240, Israel"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-original-draft","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-9394-5973","authenticated-orcid":false,"given":"Laith","family":"Khader","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Hadassah Mount Scopus Hospital, Jerusalem 91240, Israel"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"}]},{"given":"Shaden","family":"Salameh","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Hadassah Mount Scopus Hospital, Jerusalem 91240, Israel"},{"name":"Faculty of Medicine, Hadassah Hebrew University, Jerusalem 91120, Israel"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"supervision","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"project-administration","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,25]]},"reference":[{"key":"ref_1","unstructured":"Moore, E.E., Feliciano, D.V., and Mattox, K.L. (2017). The geriatric patient. Trauma, McGraw-Hill. [8th ed.]."},{"key":"ref_2","unstructured":"CDC (2020, July 28). Causes of Injury Related Death, Available online: https:\/\/wisqars-viz.cdc.gov."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"802","DOI":"10.1097\/01.TA.0000066183.02177.AF","article-title":"Preinjury warfarin use among elderly patients with closed head injuries in a trauma center","volume":"56","author":"Lavoie","year":"2004","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1097\/01.ta.0000196542.54344.05","article-title":"Traumatic brain injury in anticoagulated patients","volume":"60","author":"Cohen","year":"2006","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Antoni, A., Schwendenwein, E., Binder, H., Schauperl, M., Datler, P., and Hajdu, S. (2019). Delayed Intracranial Hemorrhage in Patients with Head Trauma and Antithrombotic Therapy. J. Clin. Med., 8.","DOI":"10.3390\/jcm8111780"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1001\/jamasurg.2017.6159","article-title":"Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma","volume":"153","author":"Chenoweth","year":"2018","journal-title":"JAMA Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.injury.2016.08.016","article-title":"Direct oral anticoagulants compared with warfarin in patients with severe blunt trauma","volume":"48","author":"Feeney","year":"2017","journal-title":"Injury"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2571","DOI":"10.1016\/j.injury.2021.05.039","article-title":"The utility of a second head CT scan after a negative initial CT scan in head trauma patients on new direct oral anticoagulants (DOACs)","volume":"52","author":"Mourad","year":"2021","journal-title":"Injury"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1007","DOI":"10.1016\/j.jamcollsurg.2021.02.016","article-title":"Delayed intracranial hemorrhage after blunt head trauma while on direct oral anticoagulant: Systematic review and meta-analysis","volume":"232","author":"Puzio","year":"2021","journal-title":"J. Am. Coll. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"451","DOI":"10.1016\/j.annemergmed.2011.12.003","article-title":"Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol","volume":"59","author":"Menditto","year":"2012","journal-title":"Ann. Emerg. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1632","DOI":"10.1016\/S0140-6736(09)60371-8","article-title":"Intracerebral haemorrhage","volume":"373","author":"Qureshi","year":"2009","journal-title":"Lancet"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1097\/TA.0000000000001414","article-title":"Novel oral anticoagulants and trauma: The results of a prospective American Association for the Surgery of Trauma Multi-Institutional Trial","volume":"82","author":"Kobayashi","year":"2017","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"126","DOI":"10.1097\/00000658-200007000-00018","article-title":"Emergency department discharge of patients with a negative cranial CT scan after minimal head injury","volume":"232","author":"Livingston","year":"2000","journal-title":"Ann. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1186\/s13049-025-01337-y","article-title":"Incidence and risk factors for delayed intracranial hemorrhage after mild brain injury in anticoagulated patients: A multicenter retrospective study","volume":"33","author":"Capsoni","year":"2025","journal-title":"Scand. J. Trauma Resusc. Emerg. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"160","DOI":"10.3892\/etm.2024.12448","article-title":"Effect of prior anticoagulation therapy on outcomes of traumatic brain injury: A systematic review and meta-analysis","volume":"27","author":"Pan","year":"2024","journal-title":"Exp. Ther. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"853","DOI":"10.1007\/s43678-022-00392-z","article-title":"Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department","volume":"24","author":"Liu","year":"2022","journal-title":"Can. J. Emerg. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1186\/s12245-023-00530-z","article-title":"Delayed intracranial hemorrhage after head trauma seems rare and rarely needs intervention\u2014Even in antiplatelet or anticoagulation therapy","volume":"16","author":"Bergenfeldt","year":"2023","journal-title":"Int. J. Emerg. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1186\/s13049-024-01214-0","article-title":"The prevalence of clinically relevant delayed intracranial hemorrhage in head trauma patients treated with oral anticoagulants: A retrospective cohort register study","volume":"33","author":"Andre","year":"2024","journal-title":"Scand. J. Trauma Resusc. Emerg. Med."},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Uccella, L., Riboni, C., Polinelli, F., Biondi, C., Uccheddu, G., Petrino, R., and Majno-Hurst, P. (2024). Use of the Canadian CT head rule for patients on anticoagulant\/anti-platelet therapy presenting with mild traumatic brain injury: Prospective observational study. Front. Neurol., 15.","DOI":"10.3389\/fneur.2024.1327871"},{"key":"ref_20","doi-asserted-by":"crossref","unstructured":"San Miguel, L., Jespers, V., and Roberfroid, D. (2026). GFAP and UCH-L1 for Ruling out Intracranial Lesions After Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis. J. Clin. Med., 15.","DOI":"10.3390\/jcm15134858"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1016\/S1474-4422(24)00454-X","article-title":"Unique considerations in the assessment and management of traumatic brain injury in older adults","volume":"24","author":"Depreitere","year":"2025","journal-title":"Lancet Neurol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e2240145","DOI":"10.1001\/jamanetworkopen.2022.40145","article-title":"Evaluation of direct oral anticoagulant reversal agents in intracranial hemorrhage: A systematic review and meta-analysis","volume":"5","author":"Chaudhary","year":"2022","journal-title":"JAMA Netw. Open."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Saran, M., Arab-Zozani, M., Behzadifar, M., Gholami, M., Azari, S., Bragazzi, N.L., and Behzadifar, M. (2024). Overuse of computed tomography for mild head injury: A systematic review and meta-analysis. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0293558"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1111\/jth.13912","article-title":"Laboratory testing in patients treated with direct oral anticoagulants: A practical guide for clinicians","volume":"16","author":"Douxfils","year":"2018","journal-title":"J. Thromb. Haemost."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"886","DOI":"10.1111\/jth.13266","article-title":"The laboratory\u2019s 2015 perspective on direct oral anticoagulant testing","volume":"14","author":"Gosselin","year":"2016","journal-title":"J. Thromb. Haemost."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"379","DOI":"10.20452\/pamw.4287","article-title":"How and when to measure anticoagulant effects of direct oral anticoagulants? Practical issues","volume":"128","author":"Tripodi","year":"2018","journal-title":"Pol. Arch. Intern. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"623","DOI":"10.1111\/jth.13227","article-title":"When and how to use antidotes for the reversal of direct oral anticoagulants: Guidance from the SSC of the ISTH","volume":"14","author":"Levy","year":"2016","journal-title":"J. Thromb. Haemost."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7465\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T08:34:53Z","timestamp":1790325293000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7465"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,25]]},"references-count":27,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197465"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197465","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,25]]}}}