Written by Amanda Mathews
Spoon Feed
This review of ground-level falls in older adults found focal neurologic signs, external signs of head trauma, loss of consciousness, and male sex were associated with a higher risk of intracranial hemorrhage (ICH). Pre-injury anticoagulant use was not associated with increased risk for ICH.
If a geriatric patient falls and no one is around to CT them, do they have ICH?
This systematic review and meta-analysis included prospective and retrospective studies of patients 65+ years old with suspected or confirmed head trauma after a ground-level fall. GCS was ≥ 13, and all patients had a head CT during their index ED visit or were systematically followed afterwards to rule out ICH. Seventeen observational studies, 22,520 patients, were included. Prevalence of traumatic ICH in this population was 6.8% (95%CI 6.5-7.2) or 1,538 patients.
Twenty-one potential risk factors were evaluated, and 16 were associated with an increased odds ratio, including single antiplatelet use (OR 1.2, 95%CI 1.0-1.3), and dual antiplatelet medication (OR 2.3, 95%CI 1.5 -3.5]). However, pre-injury anticoagulant use was not a significant risk factor (OR 0.8, 95%CI 0.7-1.0); neither warfarin (OR 1.0, 95%CI 0.8-1.4) nor DOAC (OR 0.8, 95%CI 0.6-1.0).
Seven studies provided adjusted models allowing the researchers to study 11 potential risk factors and develop adjusted odds ratios. Among those, four risk factors remained associated with traumatic ICH: focal neurologic signs (aOR 4.4, 95%CI 3.0-6.5), external sign of head trauma (aOR 2.7, 95%CI 2.1-3.5), loss of consciousness (aOR 1.6, 95%CI 1.2-2.1), and male sex (aOR 1.4, 95%CI 1.2-1.6). After adjustment, pre-injury single antiplatelet medication, reduced GCS from baseline, vomiting, and headache were no longer associated with traumatic ICH.
This study had significant heterogeneity, and most studies did not provide adjusted models. Additionally, only 6/17 studies were considered high quality.
How will this change my clinical practice?
Geriatric ground-level falls are very common. There is no decision tool to guide imaging decisions, but this adds to a previously covered study on JournalFeed calling into question whether anticoagulant use increases risk. I won’t change my practice at the moment, but further study is needed to potentially refine these tools for future use and decrease CT usage.
Source
Risk Factors for Traumatic Intracranial Hemorrhage in Older Adults Sustaining a Head Injury in Ground-Level Falls: A Systematic Review and Meta-analysis. Ann Emerg Med. 2025 Jul 22:S0196-0644(25)00313-0. doi: 10.1016/j.annemergmed.2025.05.021. Epub ahead of print. PMID: 40699169.
