Background Mild traumatic brain injury (mTBI) in patients receiving antiplatelet therapy is a frequent emergency department presentation. We aimed to describe the prevalence of traumatic intracranial lesions on the initial head computed tomography (CT) scan and the downstream in-hospital management of antiplatelet-treated adults with mTBI.Methods We conducted a retrospective bicentric cohort study in the emergency departments of Tours and Orléans University Hospitals, France. Adults receiving antiplatelet therapy who presented with mTBI (Glasgow Coma Scale score 13–15) and underwent an initial head CT scan were included. The primary outcome was the presence of any traumatic intracranial lesion on the initial CT scan. Secondary outcomes included downstream management during the index episode. An exploratory multivariable logistic regression analysis was performed using pre-CT variables.Results A total of 1,912 patients were included; mean age was 80.8 ± 12.1 years and 52.1% were women. Traumatic intracranial lesions were identified in 282 patients (14.7%). Among patients with lesions, 262 (92.9%) underwent hospital admission or 24-hour emergency department observation, 16 (5.7%) required neurosurgical management, and 104 (36.9%) underwent repeat brain imaging. In exploratory multivariable analysis, falls above standing height or high-energy falls (adjusted odds ratio [aOR] 2.84, 95% confidence interval [CI] 1.95–4.14), other trauma mechanisms (aOR 1.82, 95% CI 1.30–2.54), motor deficit at presentation (aOR 3.71, 95% CI 1.95–6.81), facial fracture (aOR 2.25, 95% CI 1.51–3.31), and temporal impact (aOR 1.94, 95% CI 1.29–2.85) were independently associated with traumatic intracranial lesions.Conclusions In antiplatelet-treated adults with mTBI, traumatic intracranial lesions were detected in approximately one in seven patients on the initial CT scan, whereas neurosurgical intervention remained uncommon. Trauma-related clinical features appeared more informative than age alone for lesion detection.