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Grandma MIGHT Have Hit Her Head…CT or Not?

January 24, 2024

Written by Nickolas Srica

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Overall rates of intracranial hemorrhage (ICH) in patients >65 years of age with either definite or uncertain head trauma were found to be 11.4% and 1.7%, respectively, leading these authors to recommend head CT imaging on all geriatric patients presenting with possible head trauma.

Five grandparents jumping on the bed, one fell off and bumped their head, maybe, actually we’re not sure…
This was a prospective cohort study of 3,855 patients presenting to two level 1 EDs in Florida where the primary outcome was ICH diagnosed on head CT for patients with definite versus uncertain head trauma. “Definite” was determined by chart review if there was a history of certain head trauma or headache, external signs of head injury on exam, or CT imaging positive for extracranial findings. If these were absent, patients were placed in the “uncertain” group. Secondary outcomes included need for neurosurgical intervention, in-hospital mortality, and 90-day mortality, and an analysis was also done to try to determine potential high-risk characteristics within the groups including anticoagulant/antiplatelet use, GCS 13-14, dementia history, alcohol and tobacco use, gender, and age >80 years.  

In the definite head trauma group, the rate of any ICH was 11.4%, while the uncertain group had a 1.7% rate: OR 7.53 (95%CI 4.54-12.51, p<0.001). The definite group also had higher rates of neurosurgical intervention at 1.2% versus 0.3%: OR 3.74 (95%CI 1.15-12.20, p=0.019). Though the definite group had several characteristics associated with increased rates of ICH, including antiplatelet use, combined antiplatelet/anticoagulant use, GCS <15, alcohol use, and male gender, the uncertain group had no characteristics found to be associated with increased ICH rates.

How will this change my practice?
It seems clear we should be getting head imaging in the “definite” head trauma group within this population. Without any well-validated clinical decision rules in this geriatric population, particularly in cases with unclear histories, I already lean more toward head CT imaging than not, and this study helps me feel a bit better about that practice. Ultimately, more research needs to be done to determine who, if anyone, can safely be excluded from imaging, and some practice pattern variation will likely remain.

Computed Tomography Imaging of Geriatric Patients with Uncertain Head Trauma. J Emerg Med. 2023 Jul 25;65(6):511-516. doi: 10.1016/j.jemermed.2023.07.009.

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