Imaging recommendation · Neuro · Head & Neck

Fall on anticoagulants

Q: What's the alternative imaging for fall on anticoagulants when initial ct positive for sdh, considering surgery?

CT — CT Head + Neurosurgery consult (no contrast).

Q: What's the alternative imaging for fall on anticoagulants when subacute presentation, characterization?

MRI — MRI Brain with gradient echo / SWI (no contrast).

Recommended: CT Head without contrast is the preferred imaging study for fall on anticoagulants. Lower threshold for imaging in anticoagulated patients.

Recommended study

CT Head without contrast

CT No contrast Preferred Neuro · Head & Neck Emergency Reviewed 2026-05

Lower threshold for imaging in anticoagulated patients. Consider repeat CT at 6 hours even if initial is negative, especially with persistent symptoms or high-risk anticoagulant.

If the default doesn't apply

Initial CT positive for SDH, considering surgery

CT CT Head + Neurosurgery consult No contrast

Subacute presentation, characterization

MRI MRI Brain with gradient echo / SWI No contrast

Watch-outs

Reversal of anticoagulation

Don't delay reversal (PCC, idarucizumab, andexanet) for repeat imaging if intracranial hemorrhage is found.

Mixed-density hematoma on first CT

Suggests acute-on-chronic bleeding — higher rebleed risk; close clinical and imaging follow-up.

Pearls

DOACs (apixaban, rivaroxaban, dabigatran) require specific reversal agents — know what's available locally.
Repeat CT at 6 hours in symptomatic anticoagulated patients with initial negative CT.
Elderly patients can present with subtle symptoms (confusion, gait change) — lower imaging threshold.