I agree there is a need for a prospective trial in view of the different
views held. Below is abstract from the 2 papers quoted.



Ray McGlone





TI  - Minor head trauma in anticoagulated patients.

AU  - Garra G; Nashed AH; Capobianco L

SO  - Acad Emerg Med 1999 Feb;6(2):121-4.



OBJECTIVE: To determine the incidence of clinically significant intracranial
injury in the anticoagulated patient suffering minor head trauma without
loss of consciousness (LOC) or acute neurologic abnormality. METHODS: A
retrospective chart review was performed based on a computerized search of
electronic patient records from six community hospital EDs, one of which is
a trauma center. Patients taking warfarin who sustained minor head trauma
without LOC having no acute neurologic abnormalities treated from January
1994 to January 1996 were identified using a search of electronic ED
records. Charts were reviewed for mechanism of injury, physical examination
findings of head injury, and concomitant injury. Prothrombin time and head
CT results were recorded if obtained. For those patients not receiving a
head CT on ED evaluation, telephone follow-up was performed to determine
outcome. RESULTS: There were 65 patients meeting inclusion criteria.
Thirty-eight patients had prothrombin times obtained, with ranges from 12.0
sec to 30.7 sec. There was no intracranial injury found in any of the 39
patients having a head CT. Additionally, follow-up on the 26 patients who
did not undergo CT scanning revealed no evidence of complications related to
their head injuries. CONCLUSIONS: The incidence of clinically significant
intracranial injury is extremely low in the anticoagulated patient suffering
minor blunt head trauma without LOC or acute neurologic abnormality. CT
scanning may not be necessary in these patients. Larger prospective studies
are needed to confirm these findings.



TI  - Mild head injury, anticoagulants, and risk of intracranial injury.

AU  - Li J; Brown J; Levine M

SO  - Lancet 2001 Mar 10;357(9258):771-2.



We studied intracranial damage in patients with mild head injuries who were
taking warfarin. Of the 215,785 individuals who visited the Mount Auburn and
Beth Israel accident and emergency departments during our study, we
identified records for 144 patients by anticoagulation status and computed
tomography (CT) imaging. We retrospectively reviewed these patients and ten
(7%, 95% CI 3-11) with clinically important injuries on cranial CT. Our
findings suggest that patients with head injuries who receive anticoagulants
have a similar or greater risk of intracranlal injury to those falling into
a previously defined moderate-risk category, invalidating a previous
conclusion that CT scanning is unnecessary in such patients.





----- Original Message -----
From: <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, January 31, 2002 10:19 PM
Subject: Warfarin and minor head injury


> A sobering personal experience has convinced me to CT scan all G.C.S 15
head
> injury patients on warfarin independent of their PT-INR.If its an acute
presentation
> it means a CT Head and admission for observation till improvement of the
minor
> symptoms(usually headache)with consideration to a repeat scan if symptoms
worsen.If
> its a delayed presentation(few days after the injury) its CT head and home
if
> scan is normal with usual HI advise.On evidence,a fellow registrar(now
consultant)did
> one of his topic reviews on the subject of management of warfarinised
patients
> with minor head injury and might want to share his opinion with the
list(unless
> he has already submitted it for publication!)To my knowledge,there are no
prospective
> studies only case reports and retrospective record reviews.The latest I
found
> was a research letter by Li and Brown reported in the Lancet(THE LANCET
Vol
> 357 March 10 2001)recommending CT scan in all patients with head injury
receiving
> anticoagulants.It refuted the earlier work by Garra(Minor head injury in
the
> warfarinised patient-Acad Emergency Med 1999 Feb;6(2) 121-4)which seemed
to
> suggest CT scan may be unnecessary in the anticoagulated patient with
minor
> blunt head injury.Personally I don't see the numbers being large if we did
go
> ahead and scan all those who present and it could be part of a multi
centre
> prospective trial to settle the question once and for all.I suggest we
call
> it the WITHMI Study(Warfarin In Traumatic Head-Minor Injury).Are you with
me?
>
> Dilip Menon
> North Wales
>