Observation of patients on anticoagulation after head injury – a systematic review and assessment of medical, economical and ethical aspects

Abstract Introduction The aim of this project was to evaluate the standard practice of observing patients treated with anticoagulants for 24 hours after a mild head injury, when an initial CT scan shows no signs of intracranial hemorrhage. Method A comprehensive search of articles was conducted in October 2024 across MEDLINE, Embase, CINAHL, and Web of Science databases, and repeated in April 2025. Selected studies were assessed by at least two independent authors, with inclusion decisions made by consensus. The studies underwent critical appraisal, and relevant data were extracted. When possible, data were pooled in a meta-analysis. For some outcomes, a narrative synthesis of data was performed. Certainty of results was evaluated using the GRADE approach. A health economic evaluation based on data retrieved from Region Skåne and the Southern Healthcare Region was also conducted, and an ethical analysis performed. Result The incidence of delayed intracranial traumatic bleeding detected by clinical deterioration during 24 hours of observation in hospital is likely to be very low. A delayed intracranial bleeding detected within 24 hours is rarely of clinical importance. Ethical considerations support that an observation period could be avoided. A health economic analysis shows that if an observation period is avoided, costs are lower, and hospital beds are made available for other patients. Discussion The results from this health technology assessment can be considered when guidelines on traumatic head injuries are revised.