Head CT in Elderly Patients on Warfarin After Ground-Level Fall
Yes, perform an emergent non-contrast head CT scan immediately—anticoagulation with warfarin is an absolute indication for head CT after any head trauma, regardless of the absence of loss of consciousness, normal GCS, or lack of obvious injury. 1, 2, 3
Primary Rationale for Imaging
Anticoagulation therapy fundamentally changes risk stratification and mandates CT imaging. The 2023 ACEP guidelines explicitly identify anticoagulant use as a critical risk factor that overrides other low-risk features. 1 Patients on warfarin have a 3.9% risk of intracranial hemorrhage compared to 1.5% in non-anticoagulated patients after head trauma. 2
Key Evidence Supporting Mandatory CT
The American College of Radiology states that patients on anticoagulation therapy have higher risk of intracranial bleeding and warrant head CT scan, even in the absence of other concerning features. 3
The 2023 ACEP clinical policy Level A recommendation indicates CT is mandatory for head trauma patients with coagulopathy, which includes therapeutic anticoagulation with warfarin. 1, 4
Age over 60-65 years is independently one of the strongest predictors of intracranial injury (odds ratio 19.2), and when combined with anticoagulation, creates compounded risk. 4
Clinical Decision Rule Application
The Canadian CT Head Rule and New Orleans Criteria both support imaging in this scenario:
Anticoagulation status alone satisfies imaging criteria independent of other risk factors. 1, 3
Ground-level falls in elderly patients on anticoagulation can cause delayed intracranial hemorrhage that may not be clinically apparent for hours to days. 2, 4
The absence of loss of consciousness does NOT exclude significant intracranial injury—1.8% of patients without LOC have intracranial injury and 0.6% require neurosurgery. 4
Critical Timing Considerations
Perform the CT scan immediately upon presentation, not after a period of observation. 2, 3 The risk of delayed hemorrhage in anticoagulated patients means that:
Early imaging is essential because anticoagulation can lead to progressive bleeding that worsens over hours. 1, 2
A normal neurologic examination at presentation does not predict absence of intracranial injury in anticoagulated patients. 1, 4
Post-CT Management Pathway
If CT is Negative:
Patients on anticoagulation with negative initial CT may NOT be appropriate for immediate discharge and require individualized assessment. 2 The standard evidence for safe discharge after negative CT explicitly excludes anticoagulated patients from the low-risk category. 2
Consider extended observation (6-24 hours) or repeat CT before discharge, as delayed hemorrhage can occur in anticoagulated patients even after initially negative imaging. 2
Provide explicit written and verbal return precautions emphasizing warning signs: worsening headache, confusion, vomiting, vision changes, weakness, or altered consciousness. 2
If CT Shows Hemorrhage:
Immediate reversal of anticoagulation is required—for warfarin, this includes vitamin K, prothrombin complex concentrate (PCC), or fresh frozen plasma. 2
Neurosurgical consultation is mandatory for any intracranial hemorrhage. 2
Admission for serial neurologic examinations and repeat imaging at 6-12 hours to assess for hemorrhage expansion. 2
Common Pitfalls to Avoid
Do not be falsely reassured by:
Normal GCS of 15—this does not exclude intracranial injury in anticoagulated patients. 1, 4
Absence of external signs of head trauma—significant intracranial injury can occur without visible external injury, especially in elderly patients with brain atrophy. 2, 4
"Ground-level" mechanism—falls from standing height in elderly anticoagulated patients carry substantial risk for intracranial hemorrhage. 3, 4
Patient's subjective feeling of being "fine"—delayed hemorrhage may not produce symptoms for hours. 2
Technical Imaging Specifications
Order non-contrast CT head only—IV contrast is NOT indicated and provides no additional benefit in acute trauma evaluation. 4 The scan should include: