Fatal Acute Subdural Hemorrhage from Low-Energy Falls

Risk Factors and Mechanisms

Adults aged ≥65 years are at significantly higher risk of severe injury and death from low-energy falls, with ground-level falls accounting for 34.6% of all deaths in this age group 1
Mortality risk increases further after age 74, with a 1.67 higher odds of death compared to those aged 65-74 years 2
Anticoagulation use significantly increases the risk of intracranial hemorrhage following even minor head injuries, with 30% of patients who died following ground-level falls being anticoagulated with aspirin, warfarin, clopidogrel, heparin, or multiple anticoagulants 3
Patients on clopidogrel had particularly high mortality rates (OR = 14.7) after traumatic intracranial hemorrhage 3
Low-energy transfers (e.g., falls from chairs or ground-level falls) can result in serious injuries, especially in older adults 1

Acute subdural hematomas can develop rapidly after head trauma due to tearing of bridging veins between the brain and dural sinuses 4
In elderly patients, brain atrophy creates more space for the brain to move during impact, increasing strain on bridging veins 2

Triage set points should be lower for elderly patients, with systolic blood pressure less than 110 mmHg considered significant 2
Polypharmacy in elderly patients can mask typical physiologic responses to trauma 2
Frailty assessment should be included in trauma evaluation of geriatric patients 2

All patients with head trauma from falls should be evaluated for risk factors for severe injury, particularly age and anticoagulation status 1, 3
Patients on anticoagulants with evidence of head injury should be transported to facilities capable of rapid evaluation, imaging, and reversal of anticoagulation 3
Elderly patients with even minor head trauma should be monitored closely for neurological deterioration, as they may not present with typical signs of serious injury 2

High-energy impacts, such as motor vehicle collisions and falls, are the primary mechanisms of injury for subdural hematomas, with 8-10% of patients with frontal sinus fractures developing subdural hematomas requiring surgical intervention 5

Anticoagulation therapy is a significant risk factor for spontaneous subdural hematomas and can worsen traumatic ones, and coagulopathies increase the risk of progressive bleeding and hematoma expansion 6
Rapid reversal of anticoagulation is critical in patients with subdural hematomas to prevent hematoma expansion, and the risk of progressive bleeding is greater when baseline CT scan is performed early after injury and when coagulopathy is present 6

In pediatric populations, subdural hematomas are the most common intracranial abnormality in abusive head trauma, often presenting as multiple, convexity, interhemispheric, or posterior fossa collections 7, 8

Non-contrast CT is the first-line imaging modality for diagnosing acute subdural hematomas, according to the American College of Radiology 5, 7
MRI provides better characterization of subacute and chronic subdural collections and can detect smaller hematomas missed on CT, and care should be taken when attempting to determine the age of subdural hematomas by imaging alone 8, 9