To scan or not to scan? Are the current NICE guidelines on investigating suspected traumatic brain injuries appropriate in the context of frailty?

Introduction

Falls are a leading cause of hospital admission in the elderly frail population. Current NICE guidance specifically recommends CT imaging as primary investigation of choice for detecting a clinically important brain injury (CIBI) in patients over age 65, with LOC/amnesia, or on anticoagulation who have sustained a head injury (HI).

Aim

To consider appropriateness of NICE guidance for CT head imaging for patients living with frailty, who present with HI following a fall from standing height.

Method

Clinical audit of 329 patients, Clinical Frailty Score 4-8, presenting with HI following a fall from standing height from January- October 2023. Demographic, clinical and outcome data was collected for each patient via Electric Patient Records and PACS imaging system.

Results

Mean age 83 (range 67-101), median CFS 6 with 31% documented long term cognitive deficit. 82% falls were unwitnessed, 23% from care home environment. 60.7% were prescribed anticoagulant/ antiplatelet (83% indication AF). 48% scan were requested at ED triage before clinical review. 57% patients were discharged from hospital <24 hours. Traumatic intracranial brain injury (tICH) was detected in 19/329 scans (5.7%), 11/19 patients with tICH were prescribed anticoagulant or antiplatelet therapy. All patients with tICH were referred for neurosurgical remote review. 18/19 were managed locally with 48 hours neuro-observation. Patients receiving anticoagulants/antiplatelets had these suspended, duration non-standardised at clinicians’ discretion. No patients experienced neurological deterioration following tICH during period of observation. 1 patient was accepted for neurosurgery presenting with acute focal neurology. Conclusion

CT imaging altered clinical management in 3.6% of patients, primarily regarding management of anticoagulation. Our data supports a review of NICE guidance to define CIBI in the context of frailty, as the majority of CT scans do not alter management/outcome. Standardising anticoagulation management in tICH dependent on indication could potentially recommend community management without CT scan and hospital review for a set cohort.