A review of Computed Tomography use in the Emergency Department for those over 65 on anticoagulants presenting with head injury

Introduction: 

The 2023 National Institute for Health and Care Excellence (NICE) guidelines advocate consideration of a Computer Tomography (CT) scan in people taking anticoagulants with sustained head injury regardless of other risk factors. In practice, this is typically implemented as a mandatory indication for imaging. We reviewed ED attendances of those aged over 65 on anticoagulation who underwent a CT following head injury, to identify factors that could indicate a higher or lower risk of radiological evidence of acute traumatic brain injury (TBI).

Methods: 

ED attendances between July and September 2025 were retrospectively analysed to identify anticoagulated people aged over 65, who had a post head injury CT scan. The data collected included evidence of visible head injury, Glasgow Coma Score (GCS), CT reports and clinical outcomes. These were assessed for associations between findings on presentation, CT results and outcomes. 

Result: 

179 attendances met the inclusion criteria. 129 (72.1%) had no visible head injury and all had no acute radiological TBI. There were 7 (3.9%) CT scans which showed acute TBIs and visible head injuries were documented in 5 of these cases.  All 7 had a GCS of 15 on presentation and none required neurosurgical intervention. Of the 5 admitted patients, 3 were discharged to their usual place of residence and 2 transferred to rehabilitation. 

Conclusion: 

The incidence of acute TBI in this cohort was low (3.9%).  Our results suggest that the risk of acute TBI in those with no visible injury on examination is very low (0%); further investigation is needed to evaluate this finding as a potential low risk factor to stratify the need for CT scanning after head injury in those over 65 on anticoagulation. A normal GCS on presentation did not exclude a TBI and it should not be used to raise the threshold for imaging.