Journal Article

Risk stratification for significant acute traumatic intracranial hemorrhage in older adults after a ground-level fall: a prospective multicentre cohort study

Émond, Marcel, Mercier, Éric, Even, Cassandre, Claessens, Yann-Érick, Dubucs, Xavier, Guenezan, Jemery, Lagache, Margaux, Barbara, Villoing, Balen, Frédéric, Pouzet, Lorraine, Sedlák, Marián, Boucher, Valérie, Morochovič, Radoslav, Charpentier, Sandrine

2026

Overview

AbstractBackgroundFalls 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.Methods and FindingsWe 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 to 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. 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, 3.5–5.6) of which five (0.3%, 95 CI% 0.1–0.7) required neurosurgical intervention, performed within a median delay of 2 days (1–4). 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, which both showed 100% sensitivity (95% CI, 95–100) with specificities ranging from 25.3% (95% CI, 23.2–27.6) to 43.6% (95% CI, 41.1–46.1). 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, 0.79–0.87) and 0.79 (95% CI, 0.74–0.84).ConclusionOur 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. 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.

• Publisher: Public Library of Science
• Subject: Geriatry and gerontology / Human health and pathology / Life Sciences