Risk stratification for significant acute traumatic intracranial hemorrhage in older adults after a ground-level...

Falls among older adults are now the leading cause of traumatic brain injury worldwide. We aimed to identify historical and clinical characteristics including the visible head impact location indicative of significant acute traumatic intracranial hemorrhage in older patients presenting to emergency department with mild traumatic brain injury subsequent to a ground-level fall.

We conducted a multicentre prospective cohort study across five university-affiliated emergency departments over a 2-year period (1 July 2023 to 30 June 2025) in Europe. We included patients aged 65 years or older who presented with mild traumatic brain injury (defined as head trauma with a Glasgow Coma Scale score of 13-15 upon emergency department presentation) following a ground-level fall and who underwent a computed tomography scan. The primary outcome was significant acute traumatic intracranial hemorrhage, defined as a neuroimaging radiological interpretation system (NIRIS) score > 1. Predictors were identified using logistic regression and recursive partitioning. A predictor was included in the decision rule if its association with the primary outcome and its interobserver reliability were strong. Using logistic regression, associations between independent variables and the outcome were adjusted for age, antithrombotic medication, and precipitating factors for the fall. Internal validation was performed using bootstrapping. The study included 1,620 patients (mean age, 84.6 ± 8.5 years). A significant acute traumatic intracranial hemorrhage was identified in 72 patients (4.4%, 95% CI [3,6]) of which five (0.3%, 95 CI% [0,1]) required urgent neurosurgical intervention. Eight criteria were identified as strong and reliable predictors: visible forehead-scalp impact, Glasgow Coma Scale score below baseline, focal neurological deficit, sign of basal skull fracture, acute confusion, vomiting, loss of consciousness, and headache. We then derived two clinical decision rules (PIWI 1 and PIWI 2), which both showed 100% sensitivity (95% CI [95,100]) with specificities ranging from 25.3% (95% CI [23,28]) to 43.6% (95% CI [41,46]). Application of either clinical decision rule would have allowed reductions (41.7% or 24.2%) of the numbers of patients sent to the CT scan unit. Internal validation confirmed the strong performance of both rules, based on C-statistics of 0.84 (95% CI [0.8,0.9]) and 0.79 (95% CI [0.7,0.9]). Because we only included patients who underwent a head CT scan during their emergency department stay, the potential for selection bias must be considered. Additionally, a risk of misclassification bias exists because we did not perform a centralized independent review of the CT scans.

Our findings revealed that factors drawn from patient history and physical examination were associated with significant acute traumatic intracranial hemorrhage in older adults after a ground-level fall. Incorporating these factors into decision rules could provide a reliable strategy to stratify risk and reduce unnecessary CT scan. We hypothesize that the PIWI 1 rule could be used in patients with a clear history of the fall, while the PIWI 2 rule could be applied in other cases. Such rules need to be validated externally and independently for their implementation in clinical practice, but may already be of aid for identifying high-risk patients.