Should a 78-year-old man with recent recurrent falls and a history of transient ischemic attack receive an urgent non‑contrast head CT?

Yes, this patient requires urgent head CT imaging

A 78-year-old man with recurrent falls in the past week and a history of TIA should be sent immediately to the emergency department for urgent non-contrast head CT imaging. 1

Rationale for Urgent Imaging

This patient meets multiple high-risk criteria that mandate immediate evaluation:

Fall-Related Head Trauma Risk

• Recurrent falls represent repeated opportunities for head trauma, even if the patient doesn't recall striking his head 1
• Elderly patients on any antiplatelet or anticoagulant therapy (commonly prescribed after TIA) have up to a 5% risk of delayed intracranial hemorrhage after head trauma, even with normal neurological examination 1
• The history of TIA strongly suggests this patient is on antiplatelet therapy (aspirin or clopidogrel) or anticoagulation, which significantly increases bleeding risk after trauma 1

TIA History Creates Urgency

• Recurrent falls in a patient with prior TIA raise concern for new cerebrovascular events causing the falls, not just mechanical instability 1, 2
• The risk of stroke after TIA is as high as 10% within the first week, and recurrent neurological symptoms (manifesting as falls) warrant immediate imaging 1, 2
• Falls could represent either: (1) new ischemic events causing weakness/ataxia, or (2) traumatic intracranial hemorrhage from the falls themselves—both require urgent CT 1

Specific Imaging Approach

Immediate Actions

• Send directly to an emergency department with CT capability without delay 1
• Obtain urgent non-contrast head CT to evaluate for:
  • Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal) 1
  • New acute ischemic stroke 1
  • Mass lesions or other structural causes of falls 1, 3

Additional Urgent Workup

• 12-lead ECG to assess for atrial fibrillation or new cardiac ischemia that could cause falls or embolic stroke 1
• Vascular imaging (CTA from arch to vertex) should be completed urgently if ischemic stroke is identified, to evaluate for large vessel occlusion or carotid stenosis 1
• Basic laboratory tests including complete blood count, coagulation studies (PT/INR, aPTT), glucose, and troponin 1

Critical Clinical Pitfalls to Avoid

Don't Wait for Neurological Deterioration

• Patients on anticoagulation/antiplatelet therapy can have delayed intracranial hemorrhage up to 8 days after trauma, even if initially neurologically intact 1
• The absence of obvious head trauma history doesn't exclude significant injury—elderly patients may not recall falls or head strikes 1

Don't Assume Falls Are Simply Mechanical

• In a patient with cerebrovascular disease history, falls may be the presenting symptom of recurrent TIA or stroke (posterior circulation events causing ataxia, anterior circulation causing leg weakness) 1, 2, 4
• "Recurrent falls in the past week" suggests either: (1) progressive neurological deficit, (2) recurrent TIA/stroke events, or (3) accumulating intracranial pathology 1, 2

Anticoagulation Status Is Critical

• If this patient is on warfarin and has intracranial hemorrhage, immediate reversal may be needed 1
• Even patients on aspirin alone (common after TIA) have increased risk of clinically significant delayed hemorrhage requiring intervention 1

Time-Sensitive Nature

This evaluation should occur within hours, not days 1:

• Patients presenting with suspected new cerebrovascular events (which recurrent falls may represent) within 48 hours are considered highest risk and require immediate ED assessment 1
• Even if the last fall was 1-2 days ago, delayed intracranial hemorrhage can evolve over this timeframe in anticoagulated patients 1
• Early identification of treatable causes (subdural hematoma, new stroke with large vessel occlusion) is time-critical for optimal outcomes 1