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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Clinical policy for the initial approach to patients presenting with altered mental status. Ann Emerg Med. 1999;33(2):251-281. Review/Other-Tx N/A N/A N/A 4
2. Leong LB, Wei Jian KH, Vasu A, Seow E. Identifying risk factors for an abnormal computed tomographic scan of the head among patients with altered mental status in the Emergency Department. Eur J Emerg Med. 17(4):219-23, 2010 Aug. Observational-Dx 967 patients To evaluate the use of computed tomographic scan of the head (CT-head) in patients with altered mental status (AMS) presenting to the Emergency Department (ED) and to identify clinical features associated with an abnormal CT-head result. Nine hundred and sixty-seven patients were recruited. The rate of CT-head use in the ED was 41%, with 45% of the scans being abnormal. We identified eight clinical factors associated with an abnormal CT-head result. Odds ratios (95% confidence intervals) for diastolic blood pressure greater than 80 mmHg, focal weakness, Glasgow Coma Score less than 15, antiplatelet use, upgoing plantar response, presence of headache, anticoagulant use and dilated pupils were 1.016 (1.003-1.029), 1.816 (1.063-3.103), 1.899 (1.113-3.242), 2.203 (1.146-4.234), 2.680 (1.623-4.427), 3.369 (1.449-7.830), 3.589 (1.253-10.283) and 5.212 (1.153-23.558), respectively. 2
3. Han JH, Wilber ST. Altered mental status in older patients in the emergency department. [Review]. Clin Geriatr Med. 29(1):101-36, 2013 Feb. Review/Other-Dx N/A To discuss the epidemiology of delirium, stupor and coma in the emergency department (ED) along with their effect on patient outcomes. No results stated in abstract. 4
4. Xiao HY, Wang YX, Xu TD, et al. Evaluation and treatment of altered mental status patients in the emergency department: Life in the fast lane. World J Emerg Med. 3(4):270-7, 2012. Observational-Tx 1934 patients To provide a framework for the assessment of Altered Mental Status patients. In 1934 patients with AMS recruited, accounting for 0.93% of all emergency department (ED) patients, 1 026 (53.1%) were male, and 908 (46.9%) female. Their average age was 51.95±15.71 years. Etiologic factors were neurological (n=641; 35.0%), pharmacological and toxicological (n=421; 23.0%), systemic and organic (n=266; 14.5%), infectious (n=167; 9.1%), endocrine/metabolic (n=145; 7.9%), psychiatric (n=71; 3.9%), traumatic (n=38; 2.1%), and gynecologic and obstetric (n=35; 1.9%). Total mortality rate was 8.1% (n=156). The death rate was higher in elderly patients (=60) than in younger patients (10.8% vs. 6.9%, P=0.003). 1
5. Salani D, Valdes B, De Oliveira GC, King B. Psychiatric Emergencies: Emergency Department Management of Altered Mental Status. [Review]. J Psychosoc Nurs Ment Health Serv. 59(9):16-25, 2021 Sep. Review/Other-Dx N/A To provide an overview of the most common disorders associated with Altered mental status (AMS), which include underlying medical conditions, substance use, and mental disorders. No results stated in the abstract. 4
6. Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165. Review/Other-Dx N/A N/A No abstract available. 4
7. Wilber ST, Ondrejka JE. Altered Mental Status and Delirium. Emerg Med Clin North Am. 2016;34(3):649-665. Review/Other-Tx N/A N/A No abstract available. 4
8. Theisen-Toupal J, Breu AC, Mattison ML, Arnaout R. Diagnostic yield of head computed tomography for the hospitalized medical patient with delirium. J Hosp Med. 9(8):497-501, 2014 Aug. Review/Other-Dx 398 patients To determine the diagnostic yield of head computed tomography when evaluating a hospitalized medical patient with delirium in the absence of a recent fall, head trauma, or new neurologic deficit. There were 398 patients hospitalized for >24 hours who underwent head computed tomography for delirium. Two hundred twenty head computed tomography studies met eligibility criteria, with 6 (2.7%) positive and 4 (1.8%) equivocal results. All positive and equivocal findings resulted in change in management. 4
9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders : DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association; 2013. Review/Other-Dx N/A Book chapter. N/A 4
10. Michaud L, Bula C, Berney A, et al. Delirium: guidelines for general hospitals. [Review] [148 refs]. J Psychosom Res. 62(3):371-83, 2007 Mar. Review/Other-Tx N/A To discuss guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients. Rated recommendations were mostly supported by a low level of evidence (1.3% randomized controlled trials (RCT) and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain. 4
11. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. One-year health care costs associated with delirium in the elderly population. Arch Intern Med. 168(1):27-32, 2008 Jan 14. Experimental-Tx 841 individuals To  determined the total 1-year health care costs associated with delirium. During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year. 2
12. Griswold KS, Del Regno PA, Berger RC. Recognition and Differential Diagnosis of Psychosis in Primary Care. [Review]. Am Fam Physician. 91(12):856-63, 2015 Jun 15. Review/Other-Dx N/A To review the differential diagnosis of psychosis in primary care. No results stated in abstract. 4
13. National Institute for Health and Care Excellence (UK). Psychosis and Schizophrenia in Adults: Treatment and Management: Updated Edition 2014. London: 2014. Review/Other-Tx N/A Book chapter. N/A 4
14. Han JH, Schnelle JF, Ely EW. The relationship between a chief complaint of "altered mental status" and delirium in older emergency department patients. Acad Emerg Med. 21(8):937-40, 2014 Aug. Observational-Dx 406 patients To determine the relationship between altered mental status as a chief complaint and delirium. A total of 406 patients were enrolled. The median age was 73.5 years old (interquartile range [IQR] = 69 to 80 years), 202 (49.8%) were female, 57 (14.0%) were nonwhite race, and 50 (12.3%) had delirium. Twenty-three (5.7%) of the cohort had chief complaints of altered mental status. The presence of this chief complaint was 38.0% sensitive (95% CI = 25.9% to 51.9%) and 98.9% specific (95% CI = 97.2% to 99.6%). The negative LR was 0.63 (95% CI = 0.50 to 0.78), and the positive LR was 33.82 (95% CI = 11.99 to 95.38). 2
15. Sporer KA, Solares M, Durant EJ, Wang W, Wu AH, Rodriguez RM. Accuracy of the initial diagnosis among patients with an acutely altered mental status. Emerg Med J. 30(3):243-6, 2013 Mar. Observational-Tx 112 patients To: (1) determine the accuracy of physician diagnosis in patients with an acutely altered mental status (AMS) within the first 20 min of emergency department (ED) presentation; and (2) access if physician confidence in early diagnosis correlates with accuracy of diagnosis. The final consensus diagnoses for AMS aetiologies were as follows: isolated alcohol intoxication 31%, other (psychotic episodes, underlying dementia) 21%, combination alcohol/other drug intoxications 18%, isolated other drug intoxications 10%, other metabolic derangements 6%, cerebrovascular accident/transient ischaemic attack 4%, seizures/post-ictal states 4%, traumatic brain injuries 3%, isolated opiate intoxications 2%, isolated benzodiazepine intoxication 1% and septic episode 1%. The emergency physician's initial diagnosis of the AMS patient correlated with the accuracy of the final diagnosis (r(2)=0.807). The quintiles of confidence of diagnosis were: 0-20% degree of confidence had a 33% diagnostic accuracy, 21-40% had 25% accuracy, 41-60% had 43% accuracy, 61-80% had 52% accuracy and those with 81-100% confidence of initial diagnosis had 78% accuracy. Of the 106 patients with an initial diagnosis, 52 (51%) had a head computed tomography (CT) performed, with eight (8%) having an acute abnormality. 2
16. American College of Radiology. ACR Appropriateness Criteria®: Cerebrovascular Diseases-Stroke and Stroke-Related Conditions. Available at: https://acsearch.acr.org/docs/3149012/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
17. Lee RK, Burns J, Ajam AA, et al. ACR Appropriateness Criteria® Seizures and Epilepsy. J Am Coll Radiol 2020;17:S293-S304. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for seizures and epilepsy. No results stated in abstract. 4
18. Shih RY, Burns J, Ajam AA, et al. ACR Appropriateness Criteria® Head Trauma: 2021 Update. J Am Coll Radiol 2021;18:S13-S36. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for head trauma. No results stated in abstract. 4
19. Whitehead MT, Cardenas AM, Corey AS, et al. ACR Appropriateness Criteria® Headache. J Am Coll Radiol 2019;16:S364-S77. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for headache. No results stated in the abstract. 4
20. Moonis G, Subramaniam RM, Trofimova A, et al. ACR Appropriateness Criteria® Dementia. J Am Coll Radiol 2020;17:S100-S12. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for dementia. No results stated in abstract. 4
21. Fan E, Shahid S, Kondreddi VP, et al. Informed consent in the critically ill: a two-step approach incorporating delirium screening. Crit Care Med. 36(1):94-9, 2008 Jan. Observational-Tx 150 patients To describe a two-step process for informed consent and evaluate the natural history of patients' competency by repeated application of this process during their hospitalization. Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) assessments (during ICU stay, at consent and hospital discharge); cumulative proportion of patients providing consent at extubation and at ICU and hospital discharge. Of 150 patients, 86 (57%) survived and 77 (90% of survivors) provided consent. Patients were delirious/deeply sedated in 89% of daily assessments during mechanical ventilation. By extubation, 31 (44%) patients passed step 1 and 8 (11%) passed step 2 and were consented. By ICU and hospital discharge, these numbers were 50 (58%) and 18 (21%), and 81 (94%) and 67 (78%), respectively. The median (interquartile range) time to patient consent after acute lung injury diagnosis was 15 (9-28) days. 4
22. Hartjes TM, Meece L, Horgas AL. CE: Assessing and Managing Pain, Agitation, and Delirium in Hospitalized Older Adults. Am. j. nurs.. 116(10):38-46, 2016 Oct. Review/Other-Dx N/A To provide an overview of each aspect of pain, agitation, and delirium (PAD), discusses clinical considerations related to the assessment and treatment of the syndrome in older adults receiving acute care, and illustrates the application of published PAD guidelines through the use of a hypothetical patient scenario. No results stated in the abstract. 4
23. Lavdas E, Mavroidis P, Kostopoulos S, et al. Improvement of image quality using BLADE sequences in brain MR imaging. Magn Reson Imaging. 31(2):189-200, 2013 Feb. Observational-Dx 67 patients To compare two types of sequences in brain magnetic resonance (MR) examinations of uncooperative and cooperative patients. For each group of patients, the pairs of sequences that were compared were two T2-weighted (T2-W) fluid attenuated inversion recovery sequences with different k-space trajectories (conventional Cartesian and BLADE) and two T2-TSE weighted with different k-space trajectories (conventional Cartesian and BLADE). No results stated in the abstract. 1
24. Acharya R, Kafle S, Shrestha DB, et al. Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status: A Systematic Review and Meta-analysis. JAMA netw. open. 5(11):e2242805, 2022 Nov 01. Meta-analysis 9338 studies (26 qualified for the systematic review and 25 for the meta-analysis) To evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies. Of 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 > 50%, P < .001), for which a random-effects model was used. There was significant publication bias, as evident by an asymmetric funnel plot. There was no fluctuation of the results during the sensitivity analysis, which reassured the reliability of the data. Good
25. Tu LH, Venkatesh AK, Malhotra A, et al. Scenarios to improve CT head utilization in the emergency department delineated by critical results reporting. EMERG. RADIOL.. 29(1):81-88, 2022 Feb. Observational-Dx 708,145 patients (58,783 CT head exams ordered) To evaluate the yield of CT head exams by scenario to guide efforts at improving patient selection. Over 708,145 adult ED encounters, 58,783 CT head exams were ordered, with an overall critical result yield of 8.0%. The three most common chief complaints had higher yield (p < 0.05): altered mental status (9.8%), fall (9.7%), and new headache (10.1%). Lower yield (p < 0.05) was found for 19 chief complaints: dizziness (6.2%), falls in patients > 65 years old (7.1%), syncope (5.3%), seizure with known epilepsy (4.8%), chest pain (3.7%), head injury (4.9%), headache re-evaluation (7.0%), alcohol intoxication (2.5%), fatigue (6.5%), headache-recurrent or in the setting of known migraines (5.2%), hypertension (4.4%), lethargy (5.8%), loss of consciousness (5.3%), migraine (3.2%), psychiatric evaluation (2.9%), near syncope (4.6%), drug problem (3.1%), symptomatically decreased blood sugar (3.2%), and suicidal (1.7%). 2
26. Choi S, Na H, Nah S, Kang H, Han S. Is brain imaging necessary for febrile elderly patients with altered mental status? A retrospective multicenter study. PLoS ONE [Electronic Resource]. 15(7):e0236763, 2020. Observational-Dx 285 patients To investigate the factors that can predict clinically significant abnormal brain imaging (ABI) in the febrile elderly with AMS. In all, 285 patients were enrolled, and 47 (16.49%) showed ABI. The most common diagnoses in patients admitted to the emergency department were intracranial hemorrhage and ischemic stroke for ABI, and pneumonia and urinary tract infection for non-ABI. In multivariate logistic regression analyses, higher systolic blood pressure (odds ratio [OR], 1.017; 95% confidence interval [CI], 1.006-1.028), lower body temperature (OR, 0.578; 95% CI, 0.375-0.892), the presence of lateralizing sign (OR, 45.676; 95% CI, 5.015-416.025), and lower Glasgow Coma Scale (OR, 0.718; 95% CI, 0.617-0.837) were significantly associated with ABI. 2
27. Oliveira J E Silva L, Berning MJ, Stanich JA, et al. Risk Factors for Delirium in Older Adults in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med. 78(4):549-565, 2021 10. Meta-analysis 34 studies To conduct a systematic review and meta-analysis to identify risk factors for delirium in geriatric patients in the emergency department and to identify emergency department (ED)-based modifiable risk factors for developing delirium during hospitalization. We searched evidence based medicine reviews, EMBASE, MEDLINE, Scopus, and Web of Science for observational studies from the time of their inception to July 2020. We included studies that evaluated potential risk factors for either prevalent or incident delirium among older adults (age = 60 years) presenting to the ED. When appropriate, we meta-analyzed estimates for risk factors using a random-effects model. The certainty of evidence was evaluated using the grading of recommendations assessment, development and evaluation approach. The study's protocol was registered in PROSPERO (CDR42020175261). A total of 4,513 citations were reviewed, and 34 studies met the criteria for inclusion: 27 evaluating risk factors for ED delirium (13,412 patients) and 7 evaluating ED-based risk factors for developing delirium during hospitalization (2,238 patients). The prevalence of ED delirium ranged from 7% to 35%. Four factors had strong associations with ED delirium and were graded as high-certainty evidence, including nursing home residence (4 studies; odds ratio [OR], 3.45; 95% confidence interval [CI], 2.17 to 5.48), cognitive impairment (7 studies; OR, 4.46; 95% CI, 3.38 to 5.89), hearing impairment (3 studies, OR, 2.57; 95% CI, 1.03 to 6.41), and a history of stroke (3 studies; OR, 3.20; 95% CI, 1.17 to 8.75). The rate of developing delirium during hospitalization ranged from 11% to 27%. A length of stay of more than 10 hours in ED was associated with a higher risk of delirium (1 study; OR, 2.23; 95% CI, 1.13 to 4.41). One study reported that severe pain, rather than the use of opioids, was associated with the development of delirium. These findings can be used to prioritize delirium screening in the ED and develop novel ED delirium risk scores or prevention interventions. Good
28. Shuaib W, Tiwana MH, Chokshi FH, Johnson JO, Bedi H, Khosa F. Utility of CT head in the acute setting: value of contrast and non-contrast studies. Ir J Med Sci. 184(3):631-5, 2015 Sep. Observational-Dx 379 patients To examine the added diagnostic value of emergent contrast enhanced computed tomography (CT) head (CECTH) in patients who present to the emergency department (ED) with acute non-traumatic symptoms referable to the brain, and to assess the financial implications of CECTH in the emergent setting. In our investigation, 379 patients-210 (55 %) females and 169 (45 %) males-met the inclusion criteria. Common indications for head CT included: headache 183 (48 %); dizziness 73 (19 %); altered mental status 49 (13 %); and seizure 38 (10 %). The mean age of study subjects was 47 (±29) years. Two hundred sixty-one (69 %) of all patients scanned showed no abnormality. One hundred eighteen (31 %) of 379 patients had abnormal scans. We encountered 1 abnormal CECTH on which non-contrast computed tomography of the head (NCTH) was normal. Cost of CECTH was $465 and NCTH was $385. 4
29. Bent C, Lee PS, Shen PY, Bang H, Bobinski M. Clinical scoring system may improve yield of head CT of non-trauma emergency department patients. EMERG. RADIOL.. 22(5):511-6, 2015 Oct. Observational-Dx 500 patients To ascertain the predictors of positive head computed tomography (CT) in non-trauma patients and demonstrate feasibility of a clinical scoring algorithm to improve yield. Positive CTs were found in 51 of 500 patients (10.2%). Only two clinical factors were significant. Focal neurologic deficit (adjusted OR 20.7; 95% CI 9.4–45.7) and age >55 (adjusted OR 3.08; CI 1.44–6.56). Area under the receiver operator characteristic (ROC) curve for all 3 algorithms were of 0.73–0.83. In proposed Algorithm C, only patients with focal neurologic deficit (major risk factor) or =2 of the five minor risk factors (altered mental status, nausea/vomiting, known malignancy, coagulopathy, and age) would undergo CT imaging. This may reduce utilization by 34% with only a small decrease in sensitivity (98%). 1
30. Khan S, Guerra C, Khandji A, Bauer RM, Claassen J, Wunsch H. Frequency of acute changes found on head computed tomographies in critically ill patients: a retrospective cohort study. J Crit Care. 29(5):884.e7-12, 2014 Oct. Observational-Dx 1607 patients To discuss the frequency of positive findings on computed tomography (CT) of the head in critically ill patients who develop neurologic dysfunction is not known. During 11 338 intensive care unit admissions, there were 901 eligible head CTs on 706 patients (6% of patients). Among head CTs, 155 (17.2%) assessed concern of new focal deficit, 99 (11.0%) concern for a seizure, and 635 (70.5%) for altered mental status (AMS). Acute changes were found on 109 (12.1%; 95% confidence interval [CI], 10.0%-14.2%) of all head CTs, and 30% (22.4%-36.9%) of patients with focal deficits, 16.2% (8.8%-23.5%) of patients with seizures but only 7.4% (5.4%-9.4%) for patients with AMS. A diagnosis of sepsis was associated with a decreased odds of an acute change on head CT for all head CTs (odds ratio 0.61; 95% CI, 0.40-0.95; P = .028) but was not significantly associated with a decreased risk among the cohort of head CTs for AMS (odds ratio 0.82; 95% CI, 0.41-1.62; P = .56). No other factors were associated with an altered risk of acute change on head CT for all patients in our cohort or for those with AMS. 2
31. Lim BL, Lim GH, Heng WJ, Seow E. Clinical predictors of abnormal computed tomography findings in patients with altered mental status. Singapore Med J. 50(9):885-8, 2009 Sep. Observational-Dx 578 patients To identify the clinical predictors of an abnormal computed tomography (CT) result in emergency department (ED) patients with altered mental status (AMS). 578 patients were recruited, of which 284 (49.1 percent) were males. 327 (56.6 percent) patients underwent CT of the brain. 128 scans (39.1 percent) were abnormal. Logistic regression revealed seven clinical features that were associated with an abnormal CT result. They were mean age greater than or equal to 73 years (OR 1.03; 95 percent confidence interval (CI) 1.015–1.045), drowsiness or unresponsiveness (OR 1.73; 95 percent CI 0.17– 17.72), previous cerebrovascular accident (OR 2.03; 95 percent CI 0.82–5.02), previous epilepsy (OR 1.63; 95 percent CI 0.63–4.19), tachycardia [greater than 120/min] (OR 1.16; 95 percent CI 0.38–3.54), bradycardia [less than 60/min] (OR 1.35; 95 percent CI 0.19–9.59) and exposure to drugs (OR 1.90; 95 percent CI 0.58–6.26). 2
32. Narayanan V, Keniston A, Albert RK. Utility of emergency cranial computed tomography in patients without trauma. Acad Emerg Med. 19(9):E1055-60, 2012 Sep. Review/Other-Dx 766 patients To determine, in patients admitted to the hospital from the emergency department (ED) without evidence of trauma, 1) the prevalence of clinically important abnormalities on cranial computed tomography (CCT) and 2) the frequency of emergent therapeutic interventions required because of these abnormalities. Of the 766 patients meeting inclusion criteria, 83 (11%) had focal neurologic findings, and 61 (8%) had clinically important abnormalities on computed tomography. Emergent interventions occurred in only 12 (1.6%), 11 (92%) of whom had focal neurologic findings. In the subgroup of 287 patients with AMS as their presenting problem, 14 (4.9%) had focal findings, six (2%) had clinically important abnormalities on tomography, and only two (0.7%) required emergent interventions, both of whom had focal findings. Patients presenting with AMS were less likely to have positive findings on tomography (odds ratio [OR] = 0.16, 95% confidence interval [CI] = 0.07 to 0.39). Patients presenting with motor weakness or speech abnormalities, or who were unresponsive, were more likely to have positive findings on tomography (OR = 4.7, 95% CI = 2.6 to 8.6; OR = 4.4, 95% CI = 1.5 to 2.7; and OR = 3.3, 95% CI = 1.6 to 7.1, respectively). 4
33. Segard J, Montassier E, Trewick D, Le Conte P, Guillon B, Berrut G. Urgent computed tomography brain scan for elderly patients: can we improve its diagnostic yield?. Eur J Emerg Med. 20(1):51-3, 2013 Feb. Review/Other-Dx 291 patients To assess the reasons for requesting an urgent computed tomography (CT) brain scan, to record the diagnostic yield of cerebral imaging, and to seek out predictive factors of an intracranial pathology. The multivariate logistic regression found that predictive factors for intracranial bleeding were localizing signs, disorders of consciousness with a Glasgow Coma Score of less than 14, head trauma, sudden-onset headache, or headache associated with at least two episodes of vomiting. 4
34. Hufschmidt A, Shabarin V. Diagnostic yield of cerebral imaging in patients with acute confusion. Acta Neurol Scand. 118(4):245-50, 2008 Oct. Observational-Dx 294 patients To find clinical predictors of normal cerebral computed tomography (CCT) or magnetic resonance imaging (MRI) scans in Acute confusion (AC). The rate of pathological imaging studies was 14%. The best single predictor of a normal brain scan was the absence of focal signs. Patients without focal abnormalities and either fever or dehydration had a probability of 0.96 of having a normal CCT or MRI. In demented patients without focal signs, the predictive value for a normal brain scan was 0.98, and if either patients with drowsiness were excluded or the existence of fever or dehydration was added as a selection criterion, all patients had normal scans. 2
35. Hammoud K, Lanfranchi M, Li SX, Mehan WA. What is the diagnostic value of head MRI after negative head CT in ED patients presenting with symptoms atypical of stroke?. EMERG. RADIOL.. 23(4):339-44, 2016 Aug. Observational-Dx 252 patients To detect the subgroup of patients with such presentations having minor strokes whom may benefit from primary and secondary stroke prevention. We conducted a retrospective analysis and stratified patient risk factors associated with positive findings on subsequent head magnetic resonance imaging (MRI) ordered by the emergency department physician following a normal head computed tomography (CT) Two hundred fifty-two patients presenting with atypical stroke symptoms to the emergency department had a negative head CT followed by head MRI within 24 h ordered by emergency department clinician (123 males and 129 females; mean age of 59.4). Twenty nine of the 252 patients (11.5 %) had findings of acute to subacute infarct on the subsequent MRI. Positive MRI findings were statistically correlated with the following variables: age (p?<?0.001), history of hyperlipidemia (p?=?0.019), hypertension (p?<?0.001), diabetes (p?=?0.004), anticoagulation use (p?=?0.029), and prior transient ischemic attack or stroke (p?<?0.001). The mean age of the MRI-positive group was 74.1 years, with a mean difference of 16.7?±?2.4 years more than the MRI-negative group (95 % CI, 11.8-21.5 years) (t?=?6.8, p?<?0.001). Emergency physicians caring for patients with vague neurologic complaints should maintain a lower threshold for ordering a head MRI despite a negative head CT for elderly patients with a history of prior stroke or transient ischemic attack to exclude a CT occult or minor ischemic stroke. 2
36. Lever NM, Nystrom KV, Schindler JL, Halliday J, Wira C 3rd, Funk M. Missed opportunities for recognition of ischemic stroke in the emergency department. J Emerg Nurs. 39(5):434-9, 2013 Sep. Observational-Dx 189 patients To determine whether an association existed between symptom presentation and diagnostic accuracy  and to identify symptom type and frequency in patients with a missed diagnosis. A diagnosis of suspected stroke was missed in 15.3% of patients who presented to the emergency department. We found a strong association (P < 0.0001) between symptom presentation and diagnostic accuracy. Of the patients presenting with any "traditional" symptom, 4% were missed. Of those presenting with only nontraditional symptoms, 64% were missed (odds ratio, 43.4; 95% confidence interval, 15.0-125.4). Nontraditional symptoms included generalized weakness, altered mental status, altered gait, and dizziness. 2
37. Albrechtsen SS, Riis RGC, Amiri M, et al. Impact of MRI on decision-making in ICU patients with disorders of consciousness. Behav Brain Res. 421:113729, 2022 03 12. Observational-Dx 75 patients To investigate the impact of brain MRI on prognostication, therapeutic decisions and physician confidence in ICU patients with disorders of consciousness (DoC). MRI led to changes in clinical management of 57 (76%) of patients (Number-Needed-to-Test for any change: 1.32), including revised diagnoses (20%), levels of care (21%), diagnostic confidence (43%) and prognostications (33%). Decisions were revised more often with stroke than with other brain injuries (p = 0.02). However, although MRI revealed additional pathology in 81%, this did not predict revised clinical decision-making (p-values =0.08). 2
38. Malatt C, Zawaideh M, Chao C, Hesselink JR, Lee RR, Chen JY. Head computed tomography in the emergency department: a collection of easily missed findings that are life-threatening or life-changing. J Emerg Med. 47(6):646-59, 2014 Dec. Review/Other-Dx N/A To discuss a collection of common emergency department (ED) cases with easily missed findings, and identify time-effective practices and patterns to minimize interpretation error. No results stated in the abstract. 4
39. Granata RT, Castillo EM, Vilke GM. Safety of deferred CT imaging of intoxicated patients presenting with possible traumatic brain injury. Am J Emerg Med. 35(1):51-54, 2017 Jan. Review/Other-Dx N/A To discuss a collection of common emergency department (ED) cases with easily missed findings, and identify time-effective practices and patterns to minimize interpretation error. No results stated in the abstract. 4
40. Sparacia G, Anastasi A, Speciale C, Agnello F, Banco A. Magnetic resonance imaging in the assessment of brain involvement in alcoholic and nonalcoholic Wernicke's encephalopathy. World J Radiol. 9(2):72-78, 2017 Feb 28. Observational-Dx 7 patients To present the typical and atypical magnetic resonance (MR) imaging findings of alcoholic and non-alcoholic Wernicke's encephalopathy. All patients with Wernicke's encephalopathy had bilateral areas showing high signal intensity on both T2-weighted and FLAIR MR images in the typical sites (i.e., the periaqueductal region and the tectal plate). Signal intensity abnormalities in the atypical sites (i.e., the cerebellum and the cerebellar vermis) were seen in 4 patients, all of which had no history of alcohol abuse. Six patients had areas with restricted diffusion in the typical and atypical sites. Four patients had areas showing contrast-enhancement in the typical and atypical sites. Follow-up MR imaging within 6 mo after therapy (intravenous administration of thiamine) was performed in 4 patients, and demonstrated a complete resolution of all the signal intensities abnormalities previously seen in all patients. 4
41. Lim CC, Gan R, Chan CL, et al. Severe hypoglycemia associated with an illegal sexual enhancement product adulterated with glibenclamide: MR imaging findings. Radiology. 250(1):193-201, 2009 Jan. Review/Other-Dx 8 patients To describe the magnetic resonance (MR) imaging findings associated with severe hypoglycemia after consumption of an illegal sexual enhancement product (Power 1 Walnut) adulterated with glibenclamide, an oral hypoglycemic agent used to treat diabetes mellitus. In seven patients, there were hyperintense abnormalities on diffusion-weighted and T2-weighted images in the hippocampus and cerebral cortex, sparing the subcortical white matter and cerebellum. Three patients had abnormalities of the splenium of the corpus callosum, and one had widespread involvement, including the caudate nucleus, basal ganglia, and internal capsule bilaterally. In three patients, unilateral cortical involvement, which did not conform to the typical cerebral arterial territories, was noted. In one patient, perfusion MR imaging showed slightly increased relative cerebral blood volume, and MR spectroscopy revealed no evidence of abnormal lactate in the affected cerebral cortex. 4
42. Goulet K, Deschamps B, Evoy F, Trudel JF. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: review and retrospective study. [Review] [37 refs]. Can J Psychiatry. 54(7):493-501, 2009 Jul. Review/Other-Dx 46 patients To identify and review available evidence on the diagnostic yield of brain computed tomographies (CTs) and magnetic resonance images (MRIs) in first-episode psychosis, and examine yield in our own institution (Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec). Five studies were deemed relevant. Including our own series, the sample comprised 384 CT and 184 MRI scans. Point estimate for diagnostic yield was 1.3% for CT and 1.1% for MRI scans. These yields likely overestimate clinical usefulness of findings. MRI scans also resulted in a sizeable number of fortuitous, clinically irrelevant findings. 4
43. Murphy R, O'Donoghue S, Counihan T, et al. Neuropsychiatric syndromes of multiple sclerosis. [Review]. J Neurol Neurosurg Psychiatry. 88(8):697-708, 2017 Aug. Review/Other-Dx N/A To review and discuss the common neuropsychiatric syndromes that occur in MS and describe the clinical symptoms, aetiology, neuroimaging findings and management strategies for these conditions. No results was stated in the abstract. 4
44. Tan Z, Zhou Y, Li X, et al. Brain magnetic resonance imaging, cerebrospinal fluid, and autoantibody profile in 118 patients with neuropsychiatric lupus. Clin Rheumatol. 37(1):227-233, 2018 Jan. Observational-Dx 118 patients To analyze clinical manifestations, features of imaging, and laboratory assessment of patients with neuropsychiatric SLE (NPSLE) for better diagnosis and outcome prediction. The abnormal changes in MRI were correlated with antiphospholipid antibody (APL) and C3 (P = 0.026 and 0.040, respectively). The most common clinical manifestation of NPSLE is headache, followed by seizures and cerebrovascular accident. The test of cerebrospinal fluid and MRI plays an important role in the assessment of NPSLE. The abnormal intracranial lesions were correlated with the level of anti-cardiolipin antibodies (ACL) and C3. 2
45. Khandanpour N, Hoggard N, Connolly DJ. The role of MRI and CT of the brain in first episodes of psychosis. Clin Radiol. 68(3):245-50, 2013 Mar. Observational-Dx 316 Patients To investigate whether imaging is associated with early detection of the organic causes of the first episode of psychosis (FEP). One hundred and twelve consecutive cerebral magnetic resonance imaging (MRI) and 204 consecutive computed tomography (CT) examinations were identified. Three (2.7%) individuals had brain lesions [brain tumour and human immunodeficiency virus (HIV) encephalopathy] potentially accountable for the psychosis at MRI. Seventy patients (62.5%) had incidental brain lesions, such as cerebral atrophy, small vessel ischaemic changes, unruptured Circle of Willis aneurysm, cavernoma, and arachnoid cysts at MRI. Three patients (1.5%) had focal brain lesions (primary or secondary tumours) potentially accountable for the psychosis at CT. One hundred and thirty-three patients (65.2%) had incidental brain lesions unrelated to the psychosis on CT scan. There was no significant difference between MRI and CT imaging in detecting organic disease potentially responsible for FEP (p < 0.001). 2
46. Robert Williams S, Yukio Koyanagi C, Shigemi Hishinuma E. On the usefulness of structural brain imaging for young first episode inpatients with psychosis. Psychiatry Res. 224(2):104-6, 2014 Nov 30. Review/Other-Dx 115 patients To determine whether structural brain imaging was clinically useful in first episode psychosis (FEP) inpatient adolescents and young adults. No results stated in the abstract. 4
47. Strahl B, Cheung YK, Stuckey SL. Diagnostic yield of computed tomography of the brain in first episode psychosis. J Med Imaging Radiat Oncol. 54(5):431-4, 2010 Oct. Review/Other-Dx 237 patients To investigate the clinical efficacy of brain CT in patients presenting with FEP without neurological signs in a major metropolitan teaching hospital. No focal brain lesion potentially responsible for the psychosis or focal lesion requiring surgical intervention was identified in any patient. Findings unable to be directly linked to the psychosis such as evidence of small vessel ischaemic disease, arachnoid cysts, cerebral atrophy, and normal variants were present in 17.6% of patients (45 of 237 studies), none of which led to an alteration of clinical management. 4
48. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on the Adult Psychiatric Patient, Nazarian DJ, Broder JS, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. [Review]. Ann Emerg Med. 69(4):480-498, 2017 Apr. Review/Other-Dx N/A This clinical policy from the American College of Emergency Physicians addresses key issues for the diagnosis and management of adult psychiatric patients in the emergency department. No results stated in abstract. 4
49. Lehman AF, Lieberman JA, Dixon LB, et al. Practice guideline for the treatment of patients with schizophrenia, second edition. [Review] [642 refs]. Am J Psychiatry. 161(2 Suppl):1-56, 2004 Feb. Review/Other-Tx N/A Practice guideline for the treatment of patients with schizophrenia. No abstract available. 4
50. Sommer IE, de Kort GA, Meijering AL, et al. How frequent are radiological abnormalities in patients with psychosis? A review of 1379 MRI scans. Schizophr Bull. 39(4):815-9, 2013 Jul. Observational-Dx 1378 patients To investigate the prevalence of clinically relevant abnormalities detected on MRI scans from psychotic patients and a matched control group. A normal aspect of the brain was reported in 74.4% of the patients and in 73.4% of the controls. We found clinically relevant pathology in 11.1% of the patients and in 11.8% of the controls. None of the neuropathological findings observed in the patients was interpreted as a possible substrate for organic psychosis. Brain abnormalities that were classified as not clinically relevant were identified in 14.5% of the patients and in 14.8% of the controls. 2
51. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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