However, the use of contrast-enhanced head CTs as a first-line test in the acute setting does not add significant value over noncontrast head CT examinations [28]. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without intravenous (IV) contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. The reported detection of treatment-altering findings on head CT is very low in elderly patients with new onset delirium unless 1 of the following risk factors is present: focal neurologic deficit, history of recent falls or head injury, anticoagulation therapy, signs of elevated intracranial pressure, or significant deterioration of consciousness [8,38-40]. Acute pathology that resulted in a change of management was detected in a small proportion of patients on head CT, including ischemic and hemorrhagic stroke, subdural hematoma, subarachnoid hemorrhage (SAH), encephalitis or meningitis, and cerebral tumors. Therefore, the low diagnostic yield of CT in this setting must be weighed against the risk of possible, preventable morbidity [8,10], acknowledging that patients may not have clinical signs on examination that predict a focal pathology [34]. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. Altered Mental Status, Coma, Delirium, and Psychosis MRI Head Without and With IV Contrast MRI examinations without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected.
Altered Mental Status Coma Delirium and Psychosis. However, the use of contrast-enhanced head CTs as a first-line test in the acute setting does not add significant value over noncontrast head CT examinations [28]. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without intravenous (IV) contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. The reported detection of treatment-altering findings on head CT is very low in elderly patients with new onset delirium unless 1 of the following risk factors is present: focal neurologic deficit, history of recent falls or head injury, anticoagulation therapy, signs of elevated intracranial pressure, or significant deterioration of consciousness [8,38-40]. Acute pathology that resulted in a change of management was detected in a small proportion of patients on head CT, including ischemic and hemorrhagic stroke, subdural hematoma, subarachnoid hemorrhage (SAH), encephalitis or meningitis, and cerebral tumors. Therefore, the low diagnostic yield of CT in this setting must be weighed against the risk of possible, preventable morbidity [8,10], acknowledging that patients may not have clinical signs on examination that predict a focal pathology [34]. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. Altered Mental Status, Coma, Delirium, and Psychosis MRI Head Without and With IV Contrast MRI examinations without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected.