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Saturday, August 15, 2026
NeurologyMedium
A 74-year-old man is brought in by his daughter for two weeks of worsening headache, mild confusion, and a new unsteady gait. He takes apixaban for atrial fibrillation and tripped on a rug about three weeks ago without striking his head, per the family. Vital signs are normal. Neurologic exam shows mild left-sided pronator drift and a wide-based gait but no other focal deficits. A non-contrast head CT is read as showing no acute hemorrhage, though the radiologist notes effacement of the right cortical sulci. Which of the following is the most appropriate next diagnostic test?
ALumbar puncture for CSF studies
BRepeat noncontrast head CT scan
CBrain MRI without IV contrast
DCarotid duplex ultrasonography
Reveal the answer & full explanation
Correct answer: C — Brain MRI without IV contrast
ALumbar puncture for CSF studies
BRepeat noncontrast head CT scan
CBrain MRI without IV contrast✓
DCarotid duplex ultrasonography
Why Brain MRI without IV contrast is correct
The picture of an elderly anticoagulated patient with a remote minor fall and a subacute course of headache, cognitive decline, gait disturbance, and contralateral pronator drift is classic for a subacute-to-chronic subdural hematoma.
A subacute subdural hematoma (about 1 to 3 weeks old) becomes isodense to brain on noncontrast CT and is easily missed; the unilateral sulcal effacement is a subtle clue to a hidden isodense collection.
MRI is the most sensitive study for small, isodense, or chronic subdural hematoma and can also help date the bleed, making it the best next step when CT is nondiagnostic but suspicion remains high.
Why the others are wrong
Repeat noncontrast head CT scan: reasonable only if the patient acutely deteriorates, but repeating the same modality that misses isodense collections will not reliably reveal a subacute subdural hematoma.
Lumbar puncture for CSF studies: used for suspected meningitis or subarachnoid hemorrhage with a negative CT, and it is hazardous when a space-occupying collection with mass effect is suspected.
Carotid duplex ultrasonography: evaluates carotid stenosis as an embolic stroke source, which does not fit this subacute, progressive, extra-axial process.
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