A Ground-Level Fall in an Anticoagulated Octogenarian
An 81-year-old woman is brought in after a mechanical fall at home in which she struck the back of her head on a doorframe. There was no loss of consciousness and she has remained alert throughout. She reports a mild occipital headache but has not vomited. Glasgow Coma Scale is 15, pupils are equal and reactive, and there is no focal deficit; a 3-cm boggy occipital hematoma is present. She takes apixaban 5 mg twice daily for atrial fibrillation, with the last dose six hours ago, and aspirin 81 mg daily. Creatinine is 1.4 mg/dL, giving an estimated creatinine clearance near 30 mL/min. Andexanet alfa is on formulary but requires pharmacy approval and costs approximately 25,000 dollars per course; four-factor prothrombin complex concentrate is stocked in the emergency department.
1. Does this patient need a head CT despite a Glasgow Coma Scale of 15? Which clinical decision rules apply, and which explicitly do not?
Read the worked answer
She needs a head CT now, and the decision does not rest on her GCS.
The common minor-head-injury rules are built around a population that excludes her. The Canadian CT Head Rule and the New Orleans Criteria were both derived and validated in patients who were not anticoagulated; anticoagulation was an exclusion criterion in the Canadian rule and is not represented in the derivation of New Orleans. Applying them here to justify skipping imaging is a misuse of the tool. This patient has at least two independent indications anyway - age over 65 and a palpable occipital hematoma.
Why the pretest probability is genuinely high: therapeutic anticoagulation, a direct-acting oral anticoagulant, reduced clearance (creatinine clearance around 30 means prolonged drug effect), and concomitant aspirin. The mechanism of injury being a ground-level fall is irrelevant; the energy required to produce intracranial bleeding in this patient is trivial.
What to do:
- Noncontrast head CT immediately, read by a clinician, not only by an overnight resident who may be several studies behind.
- Do not be reassured by a normal neurologic exam. Anticoagulated patients with intracranial hemorrhage frequently present lucid, with a GCS of 15, and deteriorate over hours.
- Do not reverse the anticoagulant before imaging. Reversal is a decision made on the CT result plus the clinical trajectory, and indiscriminate reversal exposes her to thrombotic risk.
A normal CT does not end the encounter either - she needs a defined observation period and a clear instruction on when to return.
2. The CT shows an 8-mm parietal subdural hematoma with no midline shift and no mass effect. Do you reverse, with what, and does the aspirin change your answer?
Read the worked answer
Yes, reverse - this is an intracranial hemorrhage in a patient with a fully active direct oral anticoagulant on board.
Reasoning: she took apixaban six hours ago, has a creatinine clearance near 30 (so elimination is prolonged), and has radiographic bleeding. The presence of a small, radiographically modest subdural is not a reason to withhold reversal; it is the reason to look for it early, because these lesions expand.
Options:
- Andexanet alfa, which has the better hemostatic efficacy data in this setting but carries a signal for thrombotic events and is expensive and logistically slow.
- Four-factor prothrombin complex concentrate 50 units/kg, which is immediately available, cheaper, off-label for apixaban but widely used, and reasonable when time or availability matter.
The approval-and-cost friction should not delay hemostatic therapy in a patient who is actively bleeding into the cranial vault. Start the conversation and give the drug you can give now; escalate to the other if the first is unavailable and the patient is deteriorating.
Does the aspirin change the answer? No, and it should not trigger a platelet transfusion. Aspirin is not routinely reversed, and prophylactic platelets for an antiplatelet agent in intracranial hemorrhage have not been shown to improve outcomes. Do hold the aspirin going forward and discuss with neurosurgery.
Also: neurosurgery consult, blood pressure control to reduce rebleeding risk, and reverse any coagulopathy you find.
3. Where does she go, how long do you observe her, and when does anticoagulation resume? What does the creatinine clearance contribute to your plan?
Read the worked answer
Disposition and monitoring: a unit with hourly neurologic checks and immediate access to CT - a step-down or intensive care bed, not a hallway. An 8-mm subdural in a reversibly coagulopathic patient can become a surgical lesion within hours.
Imaging: repeat noncontrast head CT at roughly 6 hours and again at 12–24 hours, and immediately for any change - new headache, vomiting, drowsiness, focal deficit, or a falling GCS. A stable repeat scan is what allows her to leave the monitored setting.
Duration of observation: at least 24 hours. The creatinine clearance of about 30 is the deciding factor - apixaban clearance is prolonged, so the window during which she can rebleed extends beyond the typical observation period for a patient with normal renal function. Even after reversal, the underlying drug elimination is slow.
Resumption of anticoagulation: not in the emergency department. This is a shared decision between neurology, neurosurgery, and cardiology, typically weeks after the hemorrhage (commonly 4–8 weeks for atrial fibrillation), weighing the stroke risk from her CHA2DS2-VASc score against the rebleeding risk. Left atrial appendage occlusion is a legitimate option to discuss. Aspirin stays on hold in the interim.
Discharge planning: if she is discharged after observation, she needs a documented written return instruction, a fall-risk assessment, and a documented plan for the anticoagulation decision - not a vague 'follow up with primary care.'