Head Injury in Older Adults: To Scan or Not to Scan? Ten Tips to Make the Best Decision

Abstract

Ground-level falls are a leading cause of emergency department (ED) visits by older adults. In addition to understanding the cause of the fall, the assessment of potential fall-induced injuries such as traumatic intracranial hemorrhage can be highly challenging for emergency clinicians. Premorbid conditions, medications, and concomitant injuries can all interfere with the physical examination and impact the prevalence of signs traditionally associated with traumatic brain injury (TBI). When it comes to the decision to potentially investigate for a traumatic intracranial hemorrhage with brain imaging such as head computed tomography (CT), many potential predictors and factors will be considered. Symptoms, history, medications, frailty, functional status, level of care, cost, and access to imaging will all potentially influence that decision-making process. This brief review article will help make that decision in the interest of the patient and the health care system. 1. Explore goals of care early. Goals of care are often one of the last things we explore with patients in the ED. However, for frail older adults, exploring goals of care should be among the first things we do, particularly relative to the decisions to investigate or not. If the head CT shows a traumatic intracranial hemorrhage, would this patient consider neurosurgery as an option? Is it aligned with their wishes? If not, you can likely stop there. Imaging is not needed and you need to focus on what is important for the patient. 2. A patient over 65 years old and mild traumatic brain injury = head CT scan Not all head traumas are TBI. A TBI is defined as a head impact associated with at least one neurologic symptom (loss of consciousness, amnesia, confusion, etc.). The recommendation for older adults who have sustained a TBI is clear: A patient ≥ 65 years old following a TBI should be investigated with brain imaging. New data suggests that this 65+ age threshold could potentially be adjusted to >75, but the safety of this cutoff needs to be confirmed with more robust data. 3. TBI-related symptoms are less predictive of intracranial hemorrhage and are often delayed. Different physiological changes associated with aging such as cerebral atrophy increase the risk of traumatic intracranial hemorrhage, even following a minor head impact. These changes leave more places for a hemorrhage to expand before becoming symptomatic compared to younger adults. Therefore, it often requires more time and a larger intracranial hemorrhage before the patient displays neurological signs or a decreased GCS. A normal physical examination cannot rule out a traumatic intracranial hemorrhage. 4. Temporal and occipital external signs of trauma increased risk of intracranial hemorrhage. The absence of external signs of trauma decreases the odds of intracranial traumatic hemorrhage. In the opposite, external signs of trauma (bruising, hematoma, or laceration) located on temporoparietal or occipital regions are associated with an increased risk of intracranial bleeding. In a large prospective Canadian cohort study, the presence of external signs of head trauma was one of the factors strongly associated with intracranial bleeding. JOURNAL OF GERIATRIC EMERGENCY MEDICINE Spring 2023 | Volume 4 | Issue 1 Article 5 | Topic Supplement | Trauma Series