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Intracranial Haemorrhage on DOAC — RACP Adult Medicine MCQ

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HardEmergency MedicineIntracranial Haemorrhage on DOACRACP Adult Medicine

A 72-year-old woman with AF on apixaban falls and sustains a head injury. CT brain shows a small subdural haematoma with no midline shift. GCS is 15. She is neurologically intact. What is the most appropriate management?

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Correct answer: D — Hold apixaban for 24–48 hours with close neurological monitoring and repeat CT

For a minor traumatic intracranial haemorrhage (small SDH, no midline shift, GCS 15) on DOAC therapy, apixaban should be held for 24–48 hours with close neurological observation and repeat CT at 6–12 hours to assess for haematoma expansion. DOAC reversal with andexanet alfa is reserved for life-threatening haemorrhage. After the acute period, a risk-benefit discussion about restarting anticoagulation (typically after 2–4 weeks) should involve neurosurgery, haematology, and the patient.

Reference: eTG – 2025 – Haematology; Neurosurgical Society of Australasia – 2024