Head CT After Fall and Head Injury
A non-contrast head CT scan is indicated for any older adult after a fall with head injury, regardless of loss of consciousness, if they have ANY of the following: age >60-65 years with physical evidence of trauma above the clavicle (including scalp/forehead injury), headache, vomiting, altered mental status (GCS <15), focal neurologic deficit, or anticoagulation therapy. 1, 2, 3
Primary Imaging Modality
Non-contrast CT of the head is the first-line imaging test for evaluating head trauma in the acute setting. 1, 4
- CT allows detection of hemorrhage, cerebral edema, intracranial mass effect, and skull fractures with high sensitivity 1
- Multiplanar reformation adds greater sensitivity for hemorrhage detection 1
- IV contrast is NOT indicated for acute head trauma evaluation 1
- CT bone algorithm reconstructions provide superior sensitivity for skull fractures compared to plain radiographs 1
Critical Decision Points for Older Adults
Age as an Independent Risk Factor
Age >60-65 years is one of the strongest predictors of intracranial injury, with an odds ratio of 19.2 for occult brain injury in patients with GCS 14-15. 3
- The combination of age >60-65 years PLUS physical evidence of trauma above the clavicle (such as forehead bruising or scalp injury) mandates CT imaging 2, 3
- Age-related brain atrophy in elderly patients means that visible external trauma indicates sufficient force to cause intracranial injury 3
Loss of Consciousness is NOT Required
The absence of loss of consciousness does NOT exclude significant intracranial injury in elderly patients. 3
- Among 491 patients without loss of consciousness, 1.8% had intracranial injury and 0.6% required neurosurgery 3
- Loss of consciousness has an odds ratio of only 1.9 for intracranial injury, meaning its absence provides limited reassurance 3
Level A Indications (Strongest Evidence)
CT is indicated in head trauma patients with loss of consciousness OR post-traumatic amnesia if ANY of the following are present: 1
- Headache
- Vomiting
- Age >60 years
- 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
Level B Indications
CT should be considered in head trauma patients WITHOUT loss of consciousness or amnesia if there is: 1
- Focal neurologic deficit
- Vomiting
- Severe headache
- Age ≥65 years
- Physical signs of basilar skull fracture
- GCS score <15
- Coagulopathy
- Dangerous mechanism of injury (fall >3 feet or 5 stairs, high-velocity MVC >35 mph, ejection from vehicle, pedestrian struck) 1
Clinical Decision Rules
Canadian CT Head Rule (More Specific)
This rule can reduce unnecessary CT scans by 37% while maintaining high sensitivity. 2
CT is indicated if ANY of the following are present: 2
- GCS <15 at 2 hours post-injury
- Suspected open or depressed skull fracture
- Signs of basilar skull fracture
- Vomiting ≥2 episodes
- Age ≥65 years
- Amnesia >30 minutes before impact
- Dangerous mechanism of injury
New Orleans Criteria (More Sensitive)
This rule is more sensitive but less specific than the Canadian CT Head Rule. 2
CT is indicated if ANY of the following are present: 2
- Headache
- Vomiting
- Age >60 years
- Drug or alcohol intoxication
- Persistent anterograde amnesia
- Visible trauma above clavicle
- Seizure
Special Considerations for This Patient
Osteoporosis and Scoliosis Context
- Osteoporosis increases fracture risk but does not independently mandate head CT 2, 3
- Scoliosis does not affect head CT indications 2, 3
- The key factors are age, mechanism (fall), and presence of head injury with physical findings 2, 3
Anticoagulation Status
Patients on anticoagulation therapy have higher risk of intracranial bleeding and warrant head CT. 2
- This includes warfarin, direct oral anticoagulants, and antiplatelet agents 2
- However, one study found anticoagulant therapy was not statistically associated with increased traumatic lesions (though clinical guidelines still recommend imaging) 5
Timing Considerations
Optimal detection of lesions occurs when CT is performed within 5 hours of head trauma. 5
- Earlier imaging may miss evolving lesions 5
- However, do not delay CT if clinical indications are present 1
Common Pitfalls to Avoid
Do not be falsely reassured by absence of loss of consciousness - this is the most dangerous pitfall, as elderly patients frequently have significant intracranial injury without LOC. 3
Do not underestimate visible trauma - a large bruise or scalp injury indicates sufficient force to cause intracranial injury in elderly patients. 3
Do not rely on skull radiographs - CT has replaced radiographs for initial evaluation as radiographs cannot characterize full extent of fractures or detect intracranial pathology. 1
Do not dismiss isolated vomiting as benign - vomiting is a validated predictor across all major clinical decision rules and warrants CT imaging. 6
Post-CT Management
If CT is negative and patient has stable neurologic examination, safe discharge is appropriate with written and verbal return precautions. 3, 6
- No routine repeat imaging is needed if initial CT is negative and patient remains neurologically stable 3
- Provide instructions to return immediately for: memory problems, confusion, worsening headache, repeated vomiting, altered consciousness, seizures, or vision problems 6
When CT May Not Be Necessary
In the rare scenario where an elderly patient has: 2, 5, 7
- No loss of consciousness
- No impact to the head
- Normal neurological examination
- No anticoagulant therapy
- No headache or vomiting
- No high-risk mechanism
- No anterograde amnesia
However, given this patient has a head injury after a fall, CT is indicated based on age alone (>60-65 years) combined with the fall mechanism and head injury. 1, 2, 3