The value of non-contrast computed tomography in the elderly after ground level falls when direct head injury is absent or uncertain – a retrospective cohort

Elderly patients after ground-level falls (GLFs) often present to the emergency department (ED) without evidence of direct head injury (EDHI) and pose a dilemma if a head computed tomography (CT) is warranted. Intracranial hemorrhage (ICH) is possible even without EDHI ascribable to challenging history and physical examination (H&P), and physiology of aging. Evaluate outcomes and risk-factors of elderly with absent or uncertain EDHI after GLFs. Methods: A single-center retrospective-cohort evaluated patients 65 or older with 'uncertain' and 'absent' EDHI on H&P upon ED presentation in consecutive sampling between 09/2019-10/2022. EDHI and multi-trauma were excluded. ICH presence was crossed with outcomes (neurosurgical intervention, disposition, and mortality) and risk-factors: cognitive decline, confusion, Glasgow Coma Scale, chronic diseases, anticoagulant or antiplatelet use, Charlson comorbidity index (CCI), Canadian Triage Acuity Score (CTAS), and past ICH. We enrolled 752 patients sub-grouped into 292 'uncertain' and 457 'absent' head injury. ICH rates were 2.8%, 2.4%, 3% and neurosurgical intervention rates were 0.8%, 0.3%, 1.1% for all patients and subgroups, respectively. CTAS 1-2 vs 3-5 showed Odds-Ratio of 5.5977 (CI 1.4149–18.3103, p=0.007) for ICH. Other associations were lower age and CCI; however, neither were significant in logistic regression. Due to the low ICH rate, and an even lower neurosurgical intervention rate, routine head CT for elderly GLFs without EDHI demands prudence. Questionable causality between GLFs and ICH and high rate of potential false-positive strengthen this claim. Considerations are recommended according to case specifics and risk-factors presented here and in the limited literature.