Is a computed tomography (CT) scan of the head indicated for an elderly patient with a large bruise to the forehead, no reported loss of consciousness (LOC), and no history of anticoagulant (blood thinner) use?

Head CT is Indicated for This Elderly Patient

Yes, obtain a non-contrast head CT scan immediately for this elderly patient with a large forehead bruise following a fall, even without loss of consciousness or anticoagulation. Age alone (>60-65 years) combined with physical evidence of trauma above the clavicle constitutes sufficient indication for imaging according to multiple validated clinical decision rules.

Primary Justification Based on Guidelines

• The NICE (National Institute for Health and Clinical Excellence) guidelines explicitly recommend CT imaging for patients with age >64 years as a high-risk criterion, particularly when combined with physical evidence of trauma above the clavicle 1

• The American College of Radiology states that elderly patients (≥60-65 years) who fall and sustain head trauma warrant head CT if they have ANY of the following: physical evidence of trauma above the clavicle, headache, vomiting, GCS <15, focal neurologic deficit, or dangerous mechanism of injury 2

• A large bruise to the forehead represents "physical evidence of trauma above the clavicle," which is an independent indication for CT scanning in elderly patients 2, 3

Evidence Supporting Age as a Critical Risk Factor

• Age >60 years carries an odds ratio of 19.2 for intracranial injury in patients with GCS scores 14-15, making it one of the strongest predictors of occult brain injury 2

• In elderly patients with mild TBI, patient age ≥65 years was identified as an independent predictor of intracranial lesions on univariate analysis, regardless of loss of consciousness 1

• Studies demonstrate that 14.3% of elderly patients (≥65 years) with minor head trauma and GCS 13-15 had intracranial injury, with 21% of those having GCS 15 and no neurologic symptoms 4

• Current clinical protocols based on symptoms alone may miss 30% of elderly patients with intracranial injury 4

Why Loss of Consciousness is NOT Required

• The absence of loss of consciousness does NOT exclude significant intracranial injury in elderly patients 1

• Research specifically challenged the premise that loss of consciousness is a reliable discriminator for neuroimaging decisions—among 491 patients without loss of consciousness, 1.8% had intracranial injury and 0.6% required neurosurgery 1

• In patients without loss of consciousness or amnesia, 4.9% still had intracranial injury and 0.5% required neurosurgical intervention 1

• Loss of consciousness has an odds ratio of only 1.9 for intracranial injury, meaning its absence provides limited reassurance 1

Clinical Decision Algorithm

Step 1: Assess age and mechanism

• Patient is elderly (age not specified but implied by "elderly patient") 2
• Fall with sufficient force to cause large forehead bruise 2

Step 2: Identify high-risk features present

• Age >60-65 years: YES 1, 2
• Physical evidence of trauma above clavicle (large bruise): YES 2, 3
• This combination alone mandates CT imaging 2

Step 3: Additional assessment to document

• GCS score (should be 15 if truly "no LOC") 1
• Presence of headache, vomiting, or amnesia 1, 2
• Focal neurologic deficits 1, 2
• Signs of basilar skull fracture 1

Step 4: Proceed with imaging

• Order non-contrast head CT immediately—do not delay 2, 3

Common Pitfalls to Avoid

• Falsely reassured by absence of loss of consciousness: This is the most dangerous pitfall, as elderly patients frequently have significant intracranial injury without LOC 1, 4

• Underestimating the significance of visible trauma: A large bruise indicates sufficient force to cause intracranial injury in elderly patients with age-related brain atrophy 2, 4

• Relying solely on normal neurologic examination: No useful clinical predictors reliably exclude intracranial injury in elderly patients with minor head trauma 4

• Assuming "no blood thinners" means low risk: While anticoagulation increases risk, elderly patients without anticoagulation still have substantial risk of intracranial hemorrhage after trauma 2, 4, 5

Supporting Evidence on Elderly-Specific Risk

• The mean age of elderly patients with intracranial pathology after head trauma was 84 years in one study, emphasizing that advanced age itself is a critical risk factor 6

• In elderly patients with low-velocity head trauma, 6.8% had intracranial hemorrhage and 1.5% required neurosurgery, even when many had no loss of consciousness 5

• A clinical prediction rule (CTHEAD) for elderly patients found that the absence of high-risk features had an NPV of only 95.1%, meaning 5% of "low-risk" elderly patients still had traumatic findings 7

If CT is Negative

• Patients with negative CT and stable neurologic examination can be safely discharged with written and verbal return precautions 3

• Provide clear instructions to return for worsening headache, vomiting, confusion, altered consciousness, or new neurologic symptoms 2, 3

• No routine repeat imaging is needed if initial CT is negative and patient remains neurologically stable 1, 3