Should I obtain a head CT for a 67‑year‑old woman after a ground‑level fall with no loss of consciousness, no obvious head injury, and no nausea or vomiting?

Head CT is NOT routinely indicated for this patient based on current evidence

A 67-year-old woman with a ground-level fall, no loss of consciousness, no head injury, and no nausea or vomiting does not meet high-risk criteria for head CT imaging according to major clinical decision rules, unless additional risk factors are present.

Risk Stratification Using Validated Clinical Decision Rules

The three major validated clinical decision rules—Canadian CT Head Rule, New Orleans Criteria, and NEXUS Head CT—all require specific high-risk features beyond age alone when there is no loss of consciousness or post-traumatic amnesia 1, 2.

High-Risk Criteria That Would Mandate CT (None Present in This Case)

• Loss of consciousness or post-traumatic amnesia (absent in this patient) 1, 3
• GCS score less than 15 (not mentioned, presumed normal) 1, 3
• Focal neurologic deficit (absent) 1, 3
• Vomiting (specifically absent in this patient) 1, 3
• Headache (not mentioned, presumed absent) 1
• Physical evidence of trauma above the clavicle (described as "no head injury") 1, 3
• Signs of basilar skull fracture (not mentioned) 1
• Post-traumatic seizure (not mentioned) 1
• Dangerous mechanism of injury (ground-level fall does not qualify) 1

Age Considerations: Critical Nuance

While age is a risk factor, the guidelines distinguish between patients with and without loss of consciousness or amnesia:

• Level A recommendation (strongest): Age >60 years mandates CT only when loss of consciousness or post-traumatic amnesia is present 1
• Level B recommendation: Age ≥65 years without loss of consciousness or amnesia is an indication to consider CT, particularly with additional risk factors 1, 2

This patient at age 67 falls into the Level B category—consideration rather than mandate—and lacks the additional risk factors that would tip the decision toward imaging 1, 2.

Anticoagulation Status: The Critical Missing Variable

You must determine anticoagulation status before making a final decision 1, 2, 4:

• Warfarin or NOACs: Absolute indication for head CT regardless of symptoms (relative risk 1.88-fold increase) 2, 4
• Dual antiplatelet therapy (aspirin + clopidogrel): Absolute indication for head CT (relative risk 2.88-fold increase) 2
• Clopidogrel alone: Strong indication for head CT 2
• Aspirin monotherapy: Does NOT significantly increase risk and does not mandate CT 2

Clinical Decision Algorithm

Step 1: Assess for High-Risk Features

• Loss of consciousness? No ✓
• Post-traumatic amnesia? No ✓
• Vomiting? No ✓
• Headache? No ✓
• Visible head trauma? No ✓
• Focal neurologic deficit? No ✓
• GCS <15? No ✓

Step 2: Assess Anticoagulation Status

• If on warfarin, NOACs, clopidogrel, or dual antiplatelet therapy → Obtain head CT immediately 2, 4
• If on aspirin alone or no anticoagulation → Proceed to Step 3 2

Step 3: Apply Age-Based Risk Stratification

• Age 67 years without loss of consciousness or amnesia = Level B consideration 1
• No additional high-risk features present = CT not indicated 1, 2

Evidence Supporting Safe Discharge Without CT

Research specifically addressing patients without loss of consciousness demonstrates very low risk:

• Among 491 patients without loss of consciousness, only 1.8% had intracranial injury and 0.6% required neurosurgery 5
• The Canadian CT Head Rule applied to patients with minimal head injury (no loss of consciousness) showed 100% sensitivity but identified that risk was very low overall 6
• A Japanese study of elderly patients (≥65 years) with minor head injury found that absence of high-risk mechanisms, vomiting, witnessed loss of consciousness, and anterograde amnesia had a 94.5% negative predictive value 7

Common Pitfalls to Avoid

• Over-reliance on age alone: Age >65 years is not an absolute indication for CT in the absence of other risk factors when there is no loss of consciousness 1, 2
• Failure to assess anticoagulation status: This is the single most important modifiable risk factor that would change management 2, 4
• Ordering CT for physician or patient reassurance: Studies show 24.6% of CTs in minimal head injury are ordered for physician reassurance and 24.2% for patient reassurance, but this is not evidence-based 6

Discharge Instructions If CT Is Deferred

Provide both written and verbal instructions to return immediately for 1, 4:

• Worsening or severe headache
• Repeated vomiting
• Confusion or altered consciousness
• Focal neurologic symptoms
• Seizure
• Increasing sleepiness or difficulty waking

Written instructions should be at sixth- to seventh-grade reading level with font size ≥12 points 4.

When to Reconsider Imaging

Obtain head CT if any of the following develop or become apparent 1, 2:

• Patient is on anticoagulants or antiplatelet agents (other than aspirin alone)
• Symptoms develop (headache, vomiting, confusion)
• Neurologic examination changes
• Patient or family reports loss of consciousness that was initially unrecognized
• Visible scalp hematoma or other evidence of trauma becomes apparent