When is a head computed tomography (CT) scan recommended for elderly patients after a fall?

When to Perform Head CT for Elderly Falls

Obtain a noncontrast head CT in elderly patients (≥60-65 years) who fall and sustain head trauma if they have ANY of the following: loss of consciousness, post-traumatic amnesia, headache, vomiting, GCS <15, focal neurologic deficit, physical evidence of trauma above the clavicle, anticoagulant or antiplatelet therapy (excluding aspirin alone), or dangerous mechanism of injury. 1

Age as an Independent Risk Factor

• Age >60 years is considered a high-risk criterion that warrants head CT imaging even in the absence of other symptoms when loss of consciousness or post-traumatic amnesia is present (Level A recommendation). 1
• For patients ≥65 years without loss of consciousness or amnesia, age alone is a Level B indication to consider head CT, particularly with additional risk factors. 1
• All three major clinical decision rules (Canadian CT Head Rule, New Orleans Criteria, and NEXUS Head CT) classify older age (60-65+ years) as high risk for clinically important brain injury. 1

Critical Indications for Head CT in Elderly Falls

With Loss of Consciousness or Post-Traumatic Amnesia:

Head CT is indicated if ANY of the following are present: 1

• Age >60 years
• Headache
• Vomiting
• Drug or alcohol intoxication
• Deficits in short-term memory
• Physical evidence of trauma above the clavicle
• Post-traumatic seizure
• GCS score <15
• Focal neurologic deficit
• Coagulopathy (anticoagulants or antiplatelet agents)

Without Loss of Consciousness or Post-Traumatic Amnesia:

Head CT should be considered if ANY of the following are present: 1

• Age ≥65 years
• Focal neurologic deficit
• Vomiting
• Severe headache
• Physical signs of basilar skull fracture
• GCS score <15
• Coagulopathy
• Dangerous mechanism (fall from >3 feet or 5 stairs)

Anticoagulation: A Critical Consideration

Patients on anticoagulants (warfarin, NOACs) or antiplatelet agents (clopidogrel, dual therapy) require head CT regardless of symptom severity. 1, 2

• Warfarin increases relative risk of significant intracranial injury by 1.88-fold. 1
• Dual antiplatelet therapy (aspirin + clopidogrel) increases relative risk by 2.88-fold. 1
• Aspirin monotherapy does NOT significantly increase risk (RR 1.29, not statistically significant), though some evidence suggests caution in patients >65 years. 1
• NOACs carry lower hemorrhage risk than warfarin (2.6% vs 10.2%) but still warrant imaging. 2
• Research shows 5.3% of elderly anticoagulated patients have intracranial hemorrhage after falls, with 5% being completely asymptomatic. 3

Clinical Decision-Making Algorithm

Step 1: Assess for High-Risk Features

• If patient has ANY high-risk feature listed above → Obtain head CT immediately 1

Step 2: Consider Mechanism and Presentation

• Unwitnessed falls, falls from bed, and falls with witnessed head strike show trends toward higher injury risk 4
• Male sex increases risk 2.19-fold 5
• History of prior traumatic brain injury increases risk 7.17-fold 5

Step 3: Timing Considerations

• Optimal detection of lesions occurs when CT is performed ≥5 hours post-trauma 5
• However, do not delay imaging if high-risk features are present 1

Follow-Up Imaging for Positive Initial CT

If initial CT shows intracranial hemorrhage in anticoagulated patients, repeat imaging is indicated as these patients have 3-fold increased risk of hemorrhage progression (26% vs 9%). 2

Common Pitfalls to Avoid

• Do NOT skip imaging in anticoagulated elderly patients even with minimal trauma or no symptoms - 5% of asymptomatic anticoagulated patients have intracranial hemorrhage. 3
• Do NOT assume aspirin monotherapy requires the same caution as other anticoagulants - evidence shows no significant increased risk with aspirin alone. 1
• Do NOT routinely obtain repeat CT at 12-24 hours in neurologically intact patients with negative initial CT - delayed hemorrhage requiring intervention is extremely rare (<1%) even in anticoagulated patients. 1, 6
• Do NOT liberally order CT without supporting clinical findings - systematic CT for all elderly falls has low yield (7.6% positive rate, only 0.6% requiring surgery). 5
• Do NOT discharge anticoagulated patients with positive CT without neurosurgical consultation and consideration of reversal agents. 2

Patients Who Can Be Safely Discharged Without CT

Elderly patients without loss of consciousness, amnesia, anticoagulation, or other high-risk features do not require routine head CT. 1, 7

• Provide clear written and verbal discharge instructions about warning signs (worsening headache, vomiting, confusion, altered consciousness). 7
• Consider fall risk assessment and anticoagulation risk-benefit evaluation for outpatient follow-up. 2