Predictors of intracranial pathologic findings in patients who seek emergency care because of headache

BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.     

The neurologic examination in adult psychiatry: from soft signs to hard science

Of the proliferating approaches to neuropsychiatric assessment, a relatively neglected technique is the venerable, accessible, noninvasive, and inexpensive neurologic examination. This article organizes and synthesizes the literature on neurological findings in adult psychiatric patients. Problems in conducting and interpreting research in this area are examined, clinically pertinent empirical findings are surveyed, and directions for future investigation are outlined. Most of the "soft signs" can be reliably evaluated, and many have been validated against other techniques. Several psychiatric diagnoses are associated with impaired neurologic performance. Prognosis and treatment selection may also be informed by neurologic findings. The neurologic exam should be regarded as a collection of neurobiologic probes rather than as a single irreducible variable. Future work must better establish interrater and test-retest reliability of individual elements of the neurologic exam in psychiatric populations and focus on developing the clinical utility of individual and combined elements of the neurologic exam.     

Computed tomography in the headache patient: is routine evaluation really necessary?

OBJECTIVE: To determine the likelihood ratio of a positive computed tomogram of the brain in the routine evaluation of headache patients. DESIGN: Consecutive patients with a chief complaint of headache were prospectively evaluated with computed tomography of the brain. Patients with headaches complicating other clinical disorders such as trauma, postictal state or known intracranial neoplasm were excluded. SETTING: Military tertiary care center. PATIENTS: Consecutive sample of 350 patients with a chief complaint of headache, regardless of the presence or absence of physical or neurologic signs, were referred for computed tomography of the brain. The patients were referred from a variety of inpatient and outpatient settings. RESULTS: Seven (2%) of the 350 patients had computed tomographic findings that were clinically significant. An additional 25 (7%) had positive computed tomographic findings, which were clinically insignificant for findings. All of the patients with significant computed tomographic findings had an abnormal physical or neurologic exam or unusual clinical symptoms. CONCLUSION: Routine computed tomography of the brain in headache patients with normal physical and neurologic exams and no unusual clinical symptoms has a low likelihood ratio for discovering significant intracranial disease.     

Cranial computed tomography in the emergency evaluation of adult patients without a recent history of head trauma: a prospective analysis

OBJECTIVES: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. METHODS: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection. X2 recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. RESULTS: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age > or = 60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94-100%) and 31% specific (95% CI: 28-33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8-13%) and 100% (95% CI: 98-100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed. CONCLUSION: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.     

Identification of ethanol-intoxicated patients with minor head trauma requiring computed tomography scans

OBJECTIVE: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol- intoxicated patients with presumed-minor head injuries. METHODS: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared. RESULTS: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9-15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2-6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchymosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour. CONCLUSION: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries and evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

Computed tomography scanning and delirium in elder patients

OBJECTIVE: 1) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions. METHODS: This was a 2-part study. Part 1 was a prospective, observational study of 560 adults > 70 years of age evaluated at 3 separate EDs using a 200-hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records (n = 279) for patients > 70 years of age in the prospective sample (n = 79) and from a sample (n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan. RESULTS: Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space-occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED. CONCLUSIONS: Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.     

Evaluation of laser and radiofrequency induced dorsal root entry zone lesion for pain control in rats

Thirty-six HIV-1-infected predominantly well-functioning subjects were followed up for one year by repeated neuropsychological, clinical neurological, neuroradiological, and immunological examinations. Changes in cognitive performance related to the severity of HIV-1 infection as well as to neuroradiological or immunological changes were studied. A decline in cognitive speed and flexibility was found in symptomatic subjects (ARC, AIDS). The impairment was especially pronounced in patients with progression of brain atrophy. These findings suggest a brain pathology underlying the cognitive decline in ambulatory outpatients with symptomatic HIV-1 infection. A practice effect was found in asymptomatic subjects (ASX, LAS) and in those with unchanged CT/MRI scans. No systematic relationship was found between cognitive change and immunological change.     

Polydactyly in a carrier of the gene for the Meckel syndrome

Localized scleroderma is distinct from the diffuse form of scleroderma and does not show Raynaud's phenomenon and visceral involvement. The imaging features in 23 patients ranging from 2 to 17 years of age (mean 11.1 years) were reviewed. Leg length discrepancy and muscle atrophy were the most common findings (five patients), with two patients also showing modelling deformity of the fibula. One patient with lower extremity involvement showed abnormal bone marrow signals on MR. Disabling joint contracture requiring orthopedic intervention was noted in one patient. In two patients with "en coup de sabre" facial deformity, CT and MR scans revealed intracranial calcifications and white matter abnormality in the ipsilateral frontal lobes, with one also showing migrational abnormality. In a third patient, CT revealed white matter abnormality in the ipsilateral parietal lobe. In one patient with progressive facial hemiatrophy, CT and MR scans showed the underlying hypoplastic left maxillary antrum and cheek. Imaging studies of areas of clinical concern revealed positive findings in half our patients.     

Critical review of the diagnostic protocol in patients with head injury

The results of a retrospective review of the conventional radiographs performed on head injury patients are reported. Skull radiography findings were compared with clinical symptoms and CT results, when CT was performed, to investigate the presence of intracranial lesions. The radiographs of 2,285 adult patients of both sexes were evaluated: skull fractures were observed in 21/2,285 patients (0.9%) only. CT was positive for an intracranial lesion in 18 of 21 patients (85.71%). Clinical symptoms were divided into three groups according to lesion severity and to neurologic impairment. 979 patients were asymptomatic and 1,306 were symptomatic: 1,114 patients were included in group I, their symptoms being nausea, vomit and loss of consciousness for less than ten minutes, 124 were included in group II (epistaxis and loss of consciousness for more than 10 minutes) and 68 were included in group III (coma and focal neurologic signs). All the patients in groups II and III and 30 patients in group I were submitted to CT--222 CT exams on the whole. Thirty-five patients in group III and 9 in group II had an intracranial lesion on CT, while CT findings were normal in all group-I patients. Thus, we conclude that the presence of a skull fracture is not always correlated with the presence of intracranial lesions. The latter are more likely to be correlated with clinical symptoms, especially coma and neurologic impairement. Therefore, the higher value is confirmed of the clinical examination than of conventional radiographs in head injury patients.     

Ten patients with refractory status epilepticus in an intensive care department

PURPOSE: Evaluation of the impact, indications, and therapeutic efficiency of chest CT in intensive-care and emergency patients. MATERIALS AND METHODS: Retrospective assessment of 741 consecutive chest CT, or which 74% were acquired in the spiral technique, in intensive-care and emergency patients. Chest CT scans and respective clinical data were compared. RESULTS: 16% of all examinations were indicated to resolve questions arising from the chest radiogram, 10% to confirm or exclude pulmonary embolisms and 10% to confirm or exclude aortic dissection. In 10% a focus of infection was sought. 57% of all CT examinations had an impact on therapy, in 7% further diagnostic tests were prompted. Among a total of 588 clinical decisions based upon chest CT, the most frequent therapeutic conclusions consisted in: minimally invasive CT guided interventions in 17%. A new drug was administered in 13%, surgical intervention was performed in 13%, bed-side interventions such as insertion of a drainage tube in 13%, and a given pharmacological therapy was continued in 11%. CONCLUSION: Chest CT has a strong impact on patient management in emergency and critical-care medicine. CT guided interventions are frequently used in critically-ill patients. The introduction of the spiral technique has led to important new CT indications in the field of non-invasive vascular diagnosis, namely the assessment of pulmonary embolism and aortic dissection.     

Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group

The stroke patient is acutely ill within minutes of symptom onset. Typically, he or she is awake and thus requires a focal neurologic exam to evaluate vision, movement, sensation and language. With the advent of acute stroke treatments that need to be rapidly implemented, it is critical that the nurse be able to assess patients and relay the information accurately and efficiently to other members of the health care team. Performing and documenting the awake stroke exam in the most efficient and useful manner is key to the nursing care of the stroke patient. The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool designed to measure the neurologic deficits most often seen with acute stroke patients. Originally designed as a research tool, it is a nonlinear ordinal scale, with possible scores ranging form 0-42. Exam performance has been timed to take 5-8 minutes. Use of the NIHSS includes documentation of neurologic status and outcome, data collection for planning safe nursing care and standardization of information exchanges between nurse caregivers and other health care professionals.     

Delusions and dementia: clinical and CT correlates

INTRODUCTION: Delusions occur frequently during the course of Alzheimer's disease (AD) and multi-infarct dementia (MID). Their clinical significance and their relationship with progression of disease and involvement of selected cerebral areas are still unclear. The aim of the study was to determine the clinical and CT correlates of delusions in patients with dementia. MATERIAL AND METHODS: A series of 67 probable AD and 32 MID patients, underwent computed tomographic scans, psychometric tests, neurologic and psychiatric examination, and blood and serum tests. RESULTS: Twenty-four patients were found to have delusions during the clinical evaluation. Delusional patients showed a significantly higher age when compared with non-delusional patients. The results of a multiple logistic regression (with stepwise deletion of the redundant variables) of the CT lesions on the presence of delusions, showed that only the presence of isolated white matter lesions in the frontal lobes were significantly related to the occurrence of delusions (Exp B = 3.42; Beta = 1.2; S.E. = 0.6; Sig T = 0.04). Frontal white matter changes were significantly related to delusions when a multiple regression analysis, entering age and total number of lesions at CT scans, was carried out. CONCLUSIONS: We found that focal lesions in the frontal areas were the only variable that appeared to be significantly and independently associated with delusional disorders.     

Delayed and progressive brain injury in closed-head trauma: radiological demonstration

The importance of delayed or secondary brain insults in the eventual outcome of closed-head trauma has been documented in experimental models. To understand this phenomenon in the clinical setting, we studied a series of head-injured patients in whom multiple cranial computed tomographic (CT) scans were obtained. Patients whose follow-up CT studies revealed new intracranial lesions or worsening, compared with admission findings, were considered to have delayed cerebral injury. One hundred forty-nine (44.5%) of 337 consecutively studied patients developed delayed brain injury. There were highly significant associations (P < 0.001) between the appearance of delayed cerebral insults and the severity of the initial brain injury, the need for cardiopulmonary resuscitation in the field, the presence of coagulopathy at admission, and subdural hematoma on the initial CT scan. In addition, delayed injury was associated (P < 0.001) with higher mortality, slowed recovery, and poorer outcome at 6 months. Delayed brain injury was not significantly associated with patient age, sex, injury mechanism, associated injury, the need for endotracheal intubation in the field, early talking, CT abnormality other than intracranial hematoma, or type of residual neurological deficits. We used multiple regression analysis to explore the relationship between severity of injury, delayed insults, and outcome. As expected, the severity of the initial brain trauma contributed significantly to neurological outcome. The presence of delayed cerebral injury makes the outcome dramatically worse for each category of initial injury severity. The relationship between initial and secondary brain injury is discussed.     

Rupture of asymptomatic mycotic aneurysm after valve replacement in infective endocarditis

Mycotic cerebral aneurysms (MCA) are one of the most serious complications of infective endocarditis. The rupture of MCA in patients under anticoagulant therapy following valve replacement carries high mortality. We encountered this serious complication in a patient who had no neurologic symptoms. A 12-year-old girl was scheduled for mitral valve replacement (MVR) 5 weeks after antibiotic therapy for infective endocarditis caused by Staphylococcus aureus. Before the surgery, she did not have any neurologic symptoms or abnormal findings in CT scanning examination. The surgery to remove her mitral valve with bacterial vegetations and replace it with an artificial valve proceeded smoothly and she appeared to begin an uneventful postoperative recovery. However, she suddenly began to complain of severe headache and became unconscious on the fifth days after MVR. A CT scan showed cerebral herniation due to a major subdural hematoma. A ruptured MCA was detected in the orbito-frontal artery and clipped in an emergency operation. She was transferred to the intensive care unit and given continuous infusion of barbiturate to prevent increase of her intracranial pressure. CT scanning and arteriography 10 days after the MCA clipping, revealed a new subdural hematoma and MCA just proximal to the previous clip. It is important to bear in mind that patients with infective endocarditis can have mycotic cerebral aneurysms without any clinical neurologic symptoms.     

Variations in the reported age of a patient: A source of bias in the diagnosis of depression and dementia.

The presence of bias in assessing organic vs depressive pathology in the elderly psychiatric population has been clinically observed in the apparent tendency to overattribute cognitive deficits to senile dementia. In the present study, 21 male and 15 female 26–49 yr old clinical psychologists were presented with a taped interview in which the age of a 64-yr-old male with depressive pseudodementia was varied (either 55 or 75 yrs). It was assumed that the ambiguity involved in determining the etiology of the patient's cognitive deficits would elicit a social or diagnostic bias related to his age. Results show the presence of a bias, with a greater attribution of organic symptoms reflective of senile dementia and fewer judgments of depression when the patient was described as elderly rather than middle-aged. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Importance of fats as energy supply, membrane building blocks and immunomodulators in parenteral nutrition

We assessed the use of cranial computed tomography (CT) in elderly patients with acute neurological deficit and its influence on patient management. Clinical notes from 100 consecutive CT referrals from geriatric admissions presenting with acute neurological deficit were reviewed and categorized according to clinical presentation. CT results and subsequent therapy were recorded. Twenty of the patients had treatable lesions (in 6 out of 14 patients with signs atypical of stroke and 7 out of 19 patients with acute confusion). These two groups contained 68% of all treatable lesions found. Forty-four scans yielded no new diagnostic information; these included all scans for transient ischaemic attacks and for progression of stroke. The remaining scans yielded information regarding pathology but did not alter patient management. CT is a valuable first-line investigation in elderly patients presenting with signs atypical of stroke and unexplained confusion but may be less useful in patients with other presentations.     

Toxoplasma encephalitis with atypical manifestation and normal CT

A case of cerebral toxoplasmosis in a HIV-positive man with unusual clinical manifestations and a normal computed tomographic (CT) scanning is presented. Even though most patients with cerebral toxoplasmosis have focal neurological deficits on physical examination, the patients can also present with more diffuse symptoms. Neither the lack of antitoxoplasma antibodies nor normal findings at CT scanning exclude the diagnosis of toxoplasma encephalitis. The sensitivity is higher with magnetic resonance than with CT scanning. We present a case story that demonstrate how delusive cerebral toxoplasmosis can be in HIV positive patients. It is recommended that the possibility of cerebral toxoplasmosis be considered in every HIV-positive patient with neurological symptoms and empirical therapy be instituted on wide indications.     

Occult fever in surgical intensive care unit patients is seldom caused by sinusitis

Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. Maxillary centeses and cultures were done in patients with CT abnormalities. Patients with positive scans had nasal tubes removed and received decongestants. Scans were abnormal in 19 (73%). All patients with major CT changes had positive maxillary taps. Most infections were polymicrobial; enteric bacilli were common. Fever resolved with nonoperative care in 18 (95%) patients; in only 1 patient was fever primarily from sinusitis. Sinus CT scans are often abnormal in ICU patients with occult fevers and transnasal cannulas. Pneumatic otoscopy can serve as a screening tool. Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.     

Neurobiological findings in first admission patients with schizophrenia or schizophreniform disorder

Fifty patients with a DSM-III-R diagnose of schizophrenia or schizophreniform disorder were compared to 25 healthy volunteers on structural and functional brain measurements. The patients were studied during their first admission to psychiatric hospital. In the patient group correlations between structural and functional brain measurements and clinical symptoms were performed. Brain structure was studied by CT scans. The schizophrenic patients had significantly smaller brain volume and brain length and more sulcal, but not ventricular, CSF than the controls. These findings were not an effect of sex, abuse, educational status or neuroleptic treatment. Brain function was studied by rCBF measurement (at baseline conditions and during mental activation), neuropsychological tests and neurological examination. The patients had significantly lower rCBF in the prefrontal regions during baseline condition and this was more pronounced during mental activation when compared with the controls. In the striatal region the patients had higher rCBF than the controls during activation. In no other region did rCBF differ between the patients and the controls. This points to a dysfunction in schizophrenic patients somewhere in th fronto-striatal-thalamic circuit. The patients performed poorer than the controls on practically all the psychological tests. Especially poor performance was seen in the more complicated tests depending on ability of abstraction, planning and sequential organisation and on semantic memory. The patients had more neurological abnormalities than the controls. Correlations between brain structure and rCBF were few. The neurological impaired patient group had more signs of structural brain deficits than the neurological normal patient group. Poor performance on a variety of psychological tests was correlated to signs of structural cerebral deficits. The significant correlations between the neurobiological measurements and clinical symptoms in the patients were sparse. However there was a trend that more symptoms both positive, negative and thought disorder were correlated to higher rCBF values in frontal, temporal and striatal regions, and that absence of positive symptoms correlated to structural brain deficits. Thus both structural and functional brain deficits can be detected early in the disease of schizophrenia. The findings point to primary cortical deficits probably located in the frontal and temporo-limbic areas.     

Linkage and association between a CD4 gene polymorphism and IDDM in Danish IDDM patients. The Danish IDDM Epidemiology and Genetics Group, and The Danish Study Group of Diabetes in Childhood

PURPOSE: Our purpose was to determine the neuroradiologic findings of Marinesco-Sj?gren syndrome on plain skull radiographs, CT, and MR images. METHODS: Eight patients with proved Marinesco-Sj?gren syndrome (age range, 4 to 56 years) had a total of nine CT scans, seven MR imaging studies, and two plain radiographic examinations of the skull. The findings were reviewed retrospectively, with particular attention to the size of the posterior fossa and cerebellum. RESULTS: All patients had hypoplastic cerebellar hemispheres and a hypoplastic vermis in a small posterior fossa. One patient had a midline posterior fossa cyst and another had agenesis of the corpus callosum. CONCLUSION: Hypoplasia of the cerebellar hemispheres and the vermis and a small posterior fossa are the most prominent neuroradiologic findings in Marinesco-Sj?gren syndrome.