CT Head for Tremors: Contrast is Not Needed
For evaluating tremors, CT head should be performed without IV contrast—there is no role for contrast-enhanced CT in this clinical scenario. 1
Why Noncontrast CT is Sufficient
Noncontrast CT head is the appropriate initial imaging modality when neuroimaging is indicated for tremor evaluation, as it adequately assesses for structural abnormalities, hemorrhage, and mass lesions that could cause secondary tremor. 1
The ACR Appropriateness Criteria explicitly state there is no relevant literature supporting the use of CT head with IV contrast for evaluating neurological symptoms like dizziness, ataxia, or related movement disorders—the same principle applies to tremor evaluation. 1
Contrast administration provides no additional diagnostic value for detecting the structural causes of tremor (stroke, mass lesions, hemorrhage, hydrocephalus) and may actually obscure certain findings. 2
When CT is Actually Indicated for Tremors
The more important question is whether CT imaging is needed at all:
Most tremors are diagnosed clinically (essential tremor, Parkinsonian tremor, physiologic tremor) and do not require neuroimaging. 3, 4
Neuroimaging is indicated when tremor presents with:
Clinical Algorithm
Perform thorough neurological examination to determine if tremor is isolated or associated with other deficits 1
If imaging is warranted, order noncontrast CT head only 1, 2
Never add contrast for tremor evaluation unless there is a separate indication unrelated to the tremor itself 1
Consider MRI brain without contrast as follow-up if CT is negative but clinical suspicion remains high for structural pathology, as MRI has superior soft tissue resolution 6
Common Pitfall to Avoid
Do not reflexively order "CT head with and without contrast" for neurological symptoms—this adds unnecessary radiation, cost, contrast exposure risk, and provides no diagnostic benefit for tremor evaluation. 1, 2