Neurologic Symptoms Requiring Head CT in Patients with Forehead Hematoma After a Fall
A non-contrast head CT scan is indicated in patients with forehead hematoma after a fall if they exhibit any of the following neurologic symptoms: decreased level of consciousness, focal neurologic deficits, seizures, persistent vomiting, severe headache, or signs of basilar skull fracture. 1, 2
Key Neurologic Symptoms Requiring Immediate CT Imaging
Altered Mental Status
- Glasgow Coma Scale (GCS) score less than 15
- Confusion or disorientation
- Amnesia (especially retrograde amnesia)
- Decreased level of consciousness
- Lethargy or somnolence
Focal Neurologic Deficits
- Weakness or numbness in extremities
- Asymmetric pupil size or reactivity
- Visual disturbances
- Speech abnormalities (slurred speech, aphasia)
- Coordination problems or ataxia
Other Critical Symptoms
- Post-traumatic seizures
- Persistent vomiting (especially projectile)
- Severe headache unresponsive to analgesics
- Signs of basilar skull fracture (raccoon eyes, Battle's sign, CSF rhinorrhea/otorrhea)
Risk Factors That Lower the Threshold for CT Imaging
Even with minimal neurologic symptoms, the following factors should lower the threshold for obtaining a head CT:
- Age greater than 60 years 1
- Anticoagulant or antiplatelet therapy 3
- History of coagulopathy
- Drug or alcohol intoxication
- Previous neurosurgery
- Dangerous mechanism of injury (fall from height > 3 feet)
Clinical Decision Rules
According to the American College of Emergency Physicians guidelines, a non-contrast head CT is indicated in head trauma patients with loss of consciousness or posttraumatic amnesia if any of the following is present:
- Headache
- Vomiting
- Age greater than 60 years
- Drug or alcohol intoxication
- Deficits in short-term memory
- Physical evidence of trauma above the clavicle (including forehead hematoma)
- Posttraumatic seizure
- GCS score less than 15
- Focal neurologic deficit
- Coagulopathy 1
Importance of Neuroimaging in Forehead Trauma
Forehead trauma is particularly concerning because:
- Proximity to frontal lobes increases risk of contusion
- Potential for frontal skull fractures that may extend to the base of skull
- Risk of epidural or subdural hematomas that may initially be asymptomatic
Common Pitfalls to Avoid
- Delayed deterioration: Patients with initially normal neurologic exams can deteriorate hours after injury due to expanding hematomas 1
- Over-reliance on GCS: Some patients with GCS of 15 may still harbor significant intracranial injuries 1
- Elderly patients: May have significant intracranial pathology with minimal symptoms due to cerebral atrophy creating space for hematoma expansion 2
- Anticoagulated patients: Higher risk for delayed hemorrhage even with minor trauma 3
Follow-up Considerations
If initial CT is negative but neurologic symptoms persist or worsen:
- Consider repeat CT imaging
- Consider MRI for higher sensitivity in detecting small contusions or axonal injuries 4
- Neurosurgical consultation for persistent symptoms despite negative imaging
In summary, the presence of any neurologic abnormality in a patient with forehead hematoma after a fall warrants prompt CT imaging to evaluate for potential intracranial injury that may require intervention to prevent morbidity and mortality.