In a 73-year-old man with no past medical history who experienced a syncopal episode and a head injury today, should I obtain a computed tomography angiography (CTA) of the head and neck, given uncertainty about whether the syncope preceded the fall?

No, Do Not Order a CTA Head and Neck

In this 73-year-old man with syncope and head injury, you should order a noncontrast head CT, not a CTA head and neck. There is no indication for CTA in the initial evaluation of acute head trauma without suspected vascular injury 1.

Recommended Imaging Approach

Order Noncontrast Head CT

Your patient meets clear criteria for noncontrast head CT based on the 2021 ACR Appropriateness Criteria 1:

• Age >60 years (he is 73)
• Physical evidence of trauma above the clavicle (head injury)
• Uncertain loss of consciousness (syncope episode)

This is a Level A recommendation from ACEP guidelines when there is head trauma with loss of consciousness or post-traumatic amnesia 1.

Why NOT CTA?

The ACR Appropriateness Criteria explicitly states: "There is no relevant literature to support the use of CT angiography (CTA) in the initial imaging evaluation of acute head trauma without suspected vascular injury" 1.

CTA head and neck is only indicated when there are specific clinical risk factors for vascular injury, such as:

• Skull base fractures involving the carotid canal
• Penetrating trauma
• Abnormal enlargement of superior ophthalmic vein/cavernous sinus
• High-grade cervical spine fractures
• Specific hemorrhage patterns suggesting arterial injury 1

Recent research confirms this approach. A 2015 study of 600 blunt TBI patients found that CTA altered management in only 1 out of 132 patients (0.8%) who received it, with most findings being incidental and unrelated to injury 2. Another 2026 study showed 74.2% of CTAs in the emergency department yielded negative results, with overutilization linked to nonadherence to established criteria 3.

Address the Syncope Separately

The syncope workup should proceed independently from the trauma imaging:

• Cardiac monitoring and ECG are the highest-yield initial tests for syncope 4
• Head CT is NOT routinely recommended for syncope evaluation unless there are focal neurological findings or head trauma 5
• Since your patient has head trauma, the noncontrast head CT serves both purposes

Common Pitfall to Avoid

Do not conflate the syncope evaluation with the trauma evaluation. The 2017 ACC/AHA/HRS syncope guidelines state: "Magnetic resonance imaging and computed tomography of the head are not recommended in the routine evaluation of patients with syncope in the absence of focal neurological findings or head injury" 5. Your patient has head injury, so CT is indicated for the trauma, not the syncope itself.

Carotid artery imaging (including CTA neck) is also not recommended in routine syncope evaluation unless there are focal neurological findings 5.

Clinical Decision Algorithm

1. Order noncontrast head CT (indicated for age >60 + head trauma)
2. Perform cardiac monitoring and ECG (for syncope evaluation)
3. Only add CTA if the noncontrast CT reveals:
   • Skull base fractures near vascular structures
   • Hemorrhage patterns suggesting arterial injury
   • Other findings suspicious for vascular pathology 1, 6

If the initial head CT shows intracranial hemorrhage AND the patient has neurological deficits on arrival, then CTA becomes more reasonable, as a 2025 study found neurological deficits were independent predictors of positive CTA findings in traumatic ICH patients 6.