Yes, a non-contrast head CT should be performed in this patient.
In a 65-year-old man with hypertension presenting with vomiting and worsening dizziness after a car ride, a non-contrast head CT is indicated based on established clinical decision rules for both head trauma and acute neurological symptoms.
Clinical Reasoning
This patient meets multiple high-risk criteria that warrant immediate neuroimaging:
Head Trauma Criteria
According to the 2021 ACR Appropriateness Criteria for head trauma 1, this patient qualifies for CT imaging under the Level B recommendation for minimal head trauma (even without documented loss of consciousness):
- Age ≥65 years (patient is 65)
- Vomiting (present)
- Mechanism of injury (car ride - potential for acceleration/deceleration forces)
The guideline specifically states that a non-contrast head CT should be considered in patients ≥65 years with head trauma when vomiting is present, regardless of whether there was witnessed loss of consciousness 1.
Acute Neurological Symptoms
The worsening dizziness is a critical red flag. While isolated dizziness has low CT yield (approximately 1-2% in research studies) 2, 3, this patient has:
- Progressive symptoms (dizziness "aggravated" = worsening)
- Associated vomiting
- Hypertension (cardiovascular risk factor)
- Age 65 (high-risk group)
Research demonstrates that acute pathology on CT in isolated vertigo occurs almost exclusively in patients with cardiovascular risk factors 2. This patient has hypertension, placing him in the higher-risk category.
Key Clinical Pitfalls to Avoid
Do not dismiss this as simple motion sickness. The combination of:
- Vomiting after mechanical trigger (car ride)
- Worsening dizziness
- Age ≥65 years
- Hypertension
creates a clinical picture that could represent:
- Posterior circulation stroke
- Intracranial hemorrhage (especially given hypertension)
- Subdural hematoma (if any head contact during car ride)
- Cerebellar pathology
Non-contrast CT is the appropriate first-line test 1, 4. It can be performed rapidly and will identify:
- Acute hemorrhage
- Large infarcts
- Mass effect
- Hydrocephalus
Important Limitations
Be aware that non-contrast CT has only 28.5% sensitivity for acute stroke 5 and may miss early posterior circulation infarcts. If the CT is negative but clinical suspicion remains high (persistent or worsening symptoms, additional neurological signs), MRI with diffusion-weighted imaging should follow 6. MRI has 79.8% sensitivity for central causes of vertigo 5 and is superior for posterior fossa pathology.
Bottom Line
Proceed with non-contrast head CT immediately. The patient's age, vomiting, hypertension, and worsening symptoms create sufficient risk to justify imaging. This aligns with Level B evidence from ACR guidelines 1 and addresses the potential for life-threatening intracranial pathology that could be missed by clinical examination alone.