What is the best initial head imaging for a 97-year-old patient presenting with headache (HA)?

From the Guidelines

The best initial head imaging for a 97-year-old patient presenting with headache is a non-contrast CT scan of the head. This recommendation is based on the most recent and highest quality evidence available, including the American College of Radiology (ACR) Appropriateness Criteria for head trauma and cerebrovascular diseases 1. The ACR guidelines emphasize the importance of non-contrast CT scans in the initial evaluation of patients with suspected intracranial pathology, particularly in the elderly population.

Key Considerations

• The patient's advanced age increases their risk for conditions like subdural hematoma, stroke, or tumors, which can be detected by a non-contrast CT scan 1.
• CT is preferred over MRI in this scenario because it is faster, more readily available in emergency settings, and better at detecting acute hemorrhage 1.
• If the CT is negative but clinical suspicion remains high for a serious condition, further imaging such as MRI or CT angiography may be warranted 1.
• The non-contrast approach is initially preferred to avoid potential contrast-related complications in this elderly patient who may have compromised renal function, though contrast may be added if needed based on initial findings 1.

Clinical Decision Rules

The ACR guidelines also discuss the use of clinical decision rules, such as the New Orleans Criteria and the Canadian CT Head Rule, to guide the decision to perform a CT scan in patients with mild head trauma 1. However, these rules may not be directly applicable to a 97-year-old patient presenting with headache, and a more individualized approach may be necessary.

Conclusion Not Applicable

Instead, the focus should be on promptly evaluating the patient with a non-contrast CT scan to rule out serious intracranial pathology, and then proceeding with further imaging or management as needed based on the results. This approach is supported by the guidelines and evidence from studies such as those published in the Journal of the American College of Radiology 1 and Stroke 1.

From the Research

Initial Head Imaging for a 97-year-old Patient with Headache

• The best initial head imaging for a 97-year-old patient presenting with headache (HA) is Computed Tomography (CT) as it is more sensitive to acute hemorrhage than Magnetic Resonance Imaging (MRI) 2.
• CT is the preferred initial imaging modality for evaluating acute headache, especially when suspecting subarachnoid hemorrhage or intraparenchymal hemorrhage 2, 3.
• MRI can be used as a secondary imaging modality to provide more detailed information and to narrow down the diagnostic possibilities, especially when the patient is stable 2.

Considerations for CT Angiography

• CT angiography (CTA) may be considered in patients with acute severe headache, normal neurological examination, and normal non-contrast CT, as it can help diagnose vascular abnormalities such as aneurysms, cerebral venous thrombosis, and reversible cerebral vasoconstriction syndrome 4, 5.
• However, the diagnostic yield of CTA in this patient population is relatively low, and its use should be justified on a case-by-case basis 5.

Importance of Lumbar Puncture

• Lumbar puncture (LP) is an important diagnostic tool in patients with suspected subarachnoid hemorrhage and normal CT scans, as it can help diagnose SAH and other conditions 3.
• LP should be performed in all cases with clinically suspected SAH and negative CT scans, as it can provide valuable diagnostic information 3.

Other Considerations

• Other imaging modalities, such as conventional tomography and MRI, may be used to evaluate specific conditions, such as temporomandibular joint dysfunction or trigeminal neuropathy 2.
• The choice of imaging modality should be based on the patient's clinical presentation, medical history, and the suspected underlying condition 2, 4, 3, 5, 6.