What head imaging is recommended for a 93-year-old female with minor head trauma?

Head Imaging Recommendations for Elderly Patients with Minor Head Trauma

A non-contrast head CT scan is strongly recommended as the initial imaging modality for this 93-year-old female patient with minor head trauma, even with a seemingly light blow to the head. 1

Rationale for Head CT in Elderly Patients

The American College of Emergency Physicians (ACEP) and the American College of Radiology (ACR) provide clear guidance for patients like this:

• Level B recommendation: Non-contrast head CT should be considered in patients with head trauma with no loss of consciousness if they are ≥65 years old, regardless of other symptoms 1
• Advanced age (>60-65 years) is a significant independent risk factor for intracranial injury, even with minor trauma 1
• The patient's age of 93 years alone warrants imaging, as the risk of clinically important traumatic brain injury increases substantially with age 1

Risk Factors Present in This Case

Several factors in this case increase the risk of intracranial injury:

• Advanced age (93 years)
• History of fall (mechanism of injury)
• Patient left against medical advice without imaging
• Injury to another body part (right leg) suggesting potentially significant impact

Why CT is Preferred Over Other Modalities

• CT is the first-line imaging modality for acute head trauma due to:
  • Speed and accessibility
  • High sensitivity for acute hemorrhage
  • Ability to detect neurosurgical lesions requiring urgent intervention 1, 2
• CT has essentially 100% sensitivity for traumatic brain injuries requiring neurosurgical intervention 1
• CT can be performed quickly without sedation, which is particularly important in elderly patients

When to Consider MRI

MRI should be considered as a follow-up study only if:

• The initial CT is negative but the patient has unexplained neurological findings
• The patient develops new neurological symptoms after a normal initial CT
• There is a need to evaluate for subtle traumatic brain injuries not visible on CT 2

MRI is more sensitive than CT for detecting:

• Small cortical contusions
• Subtle subdural hematomas
• Diffuse axonal injury
• Non-hemorrhagic axonal injury 2, 3

However, MRI is not recommended as the initial imaging modality in acute trauma due to longer acquisition times and impracticality in the emergency setting 1.

Important Considerations for Elderly Patients

• Elderly patients may develop delayed intracranial hemorrhage even after initially negative imaging 4, 5
• The risk of delayed subdural hematoma is higher in elderly patients due to age-related brain atrophy and fragile bridging veins 5
• Lower threshold for imaging is appropriate in elderly patients as they may present with minimal symptoms despite significant injury

Follow-up Recommendations

• If the initial CT is negative but symptoms persist or worsen, consider follow-up imaging
• Patient education regarding warning signs that should prompt return for evaluation (worsening headache, vomiting, confusion, weakness)
• Close follow-up is essential given the patient's age and initial decision to leave against medical advice

Common Pitfalls to Avoid

• Don't dismiss minor head trauma in elderly patients - even seemingly trivial trauma can result in significant intracranial injury
• Don't rely solely on Glasgow Coma Scale - elderly patients may have significant injury despite normal mental status
• Don't delay imaging - prompt evaluation is critical as elderly patients have higher morbidity and mortality from traumatic brain injuries
• Don't miss anticoagulant use - always check if the patient is on anticoagulants or antiplatelets, as this significantly increases bleeding risk

In conclusion, this 93-year-old patient requires immediate non-contrast head CT imaging despite the apparently minor nature of the trauma, given her advanced age and the known increased risk of intracranial injury in elderly patients.