Trip, Slip, Scan? Rethinking Head CTs in the Elderly

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Ground-level falls are a leading reason older adults get head CTs in the emergency department, largely because current clinical decision rules treat age > 65 as a risk factor by itself. Yet many emergency physicians question whether that’s always necessary for well-appearing patients. A new systematic review and meta-analysis in Annals of Emergency Medicine digs deeper, asking: what other factors truly predict intracranial hemorrhage after ground-level falls in elderly patients? Join Dr. Snyder as she explores the article’s findings, limitations, and what it means for everyday practice.

Dubucs X, Gingras V, Boucher V, et al. 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. Published online July 22, 2025. doi:10.1016/j.annemergmed.2025.05.021

Background

Obtaining CT scans of the head on older individuals presenting to the emergency department (ED) after ground level falls has become increasingly common over the last 10-15 years. Safely identifying which patients require cross sectional imaging to rule out intracranial hemorrhage is challenging as clinical decision rules to guide imaging decisions have not been specifically designed or validated for older adults. Additionally many patients over 65 have baseline cognitive impairment making history potentially unreliable. The diagnostic yield of performing CT on all patients >65 presenting with head injury is likely low with a reported prevalence of traumatic ICH at 5.2%, with fewer than 1% requiring neurosurgical intervention. So the question is: who is really at risk and how can we safely reduce unnecessary imaging?

Methods

This was a systematic review and meta-analysis of 17 observational studies aimed to identify the risk factors associated with traumatic ICH in older ED patients who sustained a ground-level fall (GLF). 

  • Population: ED patients ≥65 years with suspected or confirmed trauma to the head or face from GLF AND had a GCS 13 or above.

    • These patients either received a head CT during their index ED visit or had systematic follow up to exclude a missed traumatic ICH. 

    • Excluded high mechanism injuries.

  • Outcomes:

    • Primary Outcome: new ICH or chronic hemorrhage expansion 

    • Secondary Outcomes: urgent neurosurgical intervention, admission, in-hospital mortality (although the latter two of these were not available for majority of included studies)

  • Analysis: ORs from unadjusted models in addition to sensitivity analyses

Results

  • Sample size: 17 studies were evaluated - of these 7 were prospective and 8 were multi-center, 2 were “other”

    • 22520 total patients (39% males)

    • 6 studies were considered high quality and 11 were moderate quality

  • Traumatic ICH was identified in 1,538 patients or 6.8% of the total population evaluated 

  • Among the 6.8% of patients with ICH, urgent neurosurgery intervention prevalence was 8.0%, hospital admission rate was 36.8%, and in-hospital mortality was 1.5% 

  • They then assessed risk factors, I am going to group these into three categories

    • Patient factors - sex; cognitive impairment; use of anticoagulation, antiplatelet, or aspirin; CKD; presence of headache

    • Historical features - LOC, amnesia, seizure, vomiting

    • Exam - GCS, suspected skull fracture, focal neurologic deficit, external sign of head trauma, alcohol intoxication 

The majority of identified risk factors were associated with increased risk of ICH but surprisingly DOAC, warfarin, and alcohol intoxication were not. Risk factors with odds ratios included:

  • suspected open or depression skull fracture - OR 10.96

  • signs of basal skull fracture - OR 4.69

  • reduced GCS from baseline - OR 3.97

  • focal neurological sign - OR 3.80

  • seizure - OR 3.21

  • vomiting - OR 2.70

  • amnesia - OR 2.42

  • loss of consciousness- OR 2.30

  • dual anti platelet - OR 2.29

  • headache - OR 2.11

  • visible head trauma - OR 1.96

  • male - OR 1.45

  • single anti platelet other than asa - OR 1.42

  • chronic kidney disease - OR 1.36

  • asa alone - OR 1.24

  • single anti platelet - OR 1.16

For ease of remembering, risk factors can be grouped into three larger categories:

  • Patient factors - sex; cognitive impairment; use of anticoagulation, antiplatelet, or aspirin; CKD; presence of headache

  • Historical features - LOC, amnesia, seizure, vomiting

  • Exam - GCS, suspected skull fracture, focal neurologic deficit, external sign of head trauma, alcohol intoxication

Seven studies provided adjustment data and after adjusting for sex, preinjury cognitive impairment, single antiplatelet, VKA, acetylsalicylic acid alone, focal neurologic sign, headache, loss of consciousness, vomiting, reduced baseline GCS score, and external sign of head trauma only focal neurologic signs, external sign of head trauma, loss of consciousness, and male sex remained associated with increased risk of ICH. 

Limitations

  • Meta-analysis of heterogenous studies which were mostly mono-centric and of varying quality 

  • There may be an indication bias at play, patients receiving anticoagulants likely undergo head CT scans more frequently than those not on AC. This may result in a higher frequency of negative head CT scans, lowering the prevalence of traumatic ICH within this group. 

  • There was only a binary primary outcome of ICH present (yes or no) - whereas the severity and clinical relevance were not reported. This type of information may be helpful in delineating future clinical decision rules for elderly patients.

Conclusions

  • Main risk factors for ICH in GLF in the elderly: Reduced GCS, focal neurologic signs, skull fracture signs, external head trauma, and symptoms like loss of consciousness or vomiting were associated with higher ICH risk.

  • The results suggest that after GLF, anticoagulants may not be associated with an increased risk of traumatic ICH. They did not offer a physiologic explanation for this. 

Clinical takeaway: Older adults have unique ICH risk patterns, but there is not yet enough evidence to state that head CT only be ordered in certain patients over 65 just yet.

Final Recommendations

  • This is not yet practice changing but will hopefully lead to development of a clinical decision rule.

AUTHORSHIP

Written by: Bonnie Synder, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Editing, Posting, and Audio Editing by Anita Goel, MD Adjunct Associate Professor, University of Cincinnati Department of Emergency Medicine.

Cite as: Synder, B., Goel, A. Trip, Slip, Scan? Rethinking Head CTs in the Elderly. TamingtheSRU.com. www.tamingthesru.com/blog/journal-club-head-cat-scans-in-the-elderly-fall. 12/29/2025.