Head CT Evaluation for Unwitnessed Falls

Clinical Decision Rules for Head CT After Falls

The American College of Radiology recommends that imaging is usually not appropriate for patients with mild head trauma (GCS 13-15) when not indicated by clinical decision rules 1, 2
The American College of Radiology suggests that head CT is appropriate when clinical decision rules indicate the need for imaging 1

The Canadian CT Head Rule identifies suspected open skull fracture as a high-risk factor for neurosurgical intervention 1
The Canadian CT Head Rule identifies any sign of basal skull fracture as a high-risk factor for neurosurgical intervention 1
The Canadian CT Head Rule identifies vomiting >2 episodes as a high-risk factor for neurosurgical intervention 1
The Canadian CT Head Rule identifies age >65 years as a high-risk factor for neurosurgical intervention 1

The American College of Emergency Physicians recommends that head CT is indicated with loss of consciousness or post-traumatic amnesia if any of the following are present: headache, vomiting, age >60, intoxication, short-term memory deficits, trauma above clavicle, post-traumatic seizure, GCS <15, focal deficit, or coagulopathy 1
The American College of Emergency Physicians recommends that head CT should be considered with no loss of consciousness or post-traumatic amnesia if any of the following are present: focal deficit, vomiting, severe headache, age ≥65, basilar skull fracture signs, GCS <15, coagulopathy, or dangerous mechanism 1

The American College of Radiology recommends that non-contrast head CT is the appropriate initial imaging study for patients with high-risk features 1
The use of skull radiographs instead of CT is not recommended, as radiographs cannot characterize the full extent of fractures or intracranial pathology 3

The American College of Radiology recommends non-contrast head CT as the appropriate initial imaging study for patients with head trauma and any high-risk features 4
Head CT is the most useful initial imaging for evaluation of acute head trauma, regardless of severity 5, 6
The inclusion of multiplanar reformatted images in the CT protocol increases diagnostic accuracy 6

Head CT has revolutionized the management of acute head trauma by enabling detection of neurosurgical lesions such as hemorrhage, herniation, and hydrocephalus 6
Even in mild head trauma, approximately 10% will have positive findings on head CT, and 1% will require neurosurgical intervention 4

If the initial CT is normal but the patient's neurological status deteriorates, a repeat CT or MRI should be considered 7
For subacute or chronic head trauma, MRI may be more appropriate than CT as it is more sensitive for subtle findings adjacent to the calvarium or skull base 8, 9
Patients with a normal CT and normal neurological examination have a very low risk (0.006%) of deterioration 7