Head Ct and MRIs on patients with potential Cognitive D/O

[Faebinder]

Do you guys see a point for ever doing a CT scan or an MRI on a patient who is psychotic/manic and potentially has a cognitive do with no history of trauma?

---

Members don't see this ad.

 

[whopper]

Depends.

If you're suspecting cognitive disorder NOS, the DSM reccomends neuropsychological testing & objective medical data. A scan can fit the "objective medical data" part.

 

[kugel]

they're are some books and some practitioners who believe that every new change of mental status gets a scan. It's really terrible when someone is treated psychiatrically for months, years, decades and a correctable problem was never diagnosed. It's somewhat rare, but it certainly does happen.

Others do it only when there's an atypical presentation of some sort or a specific reason (hd injury, or other item pointing to a scannable problem).

Still others won't scan a psychiatric patient until something is growing out of the side of the pt's head.

IMHO, ANY acute onset unexplained altered mental status deserves a scan, ANY mental status change with neuro symptoms deserves a scan.

These days, it's no longer a stretch to give every pt with serious mental illness a scan at first presentation.

Remember, psych patients CAN get tumors, meningitis, encephalitis, HIV, etc. and sometimes it's your job to point that out to the ED, Int Med, Neuro consultant. Probably should never skip a scan in a psych pt where the symptoms would prompt you to scan a non-psych patient. I think a plaintiff's attorney would LOVE to hear you say, "Well, because he has schizophrenia, we just didn't really pay much attention to his complaints."

One easy way to go is to utilize the steps in the Washington Manual. It also makes it easy to argue to other providers for further diagnostics. "I'm reading this out of the 2008 edition of the Wash Manual. What edition are you using?"

 

[PsyDGrrrl]

A CT or MRI only shows structural abnormalities, however, and there is a lot that can be going wrong cognitively that won't be seen in a picture of the brain. A PET scan or fMRI can show areas where the brain isn't functioning. But like Whopper said, standard of practice includes neuropsychological testing which will give you fairly detailed, objective data of where the problems are and what kind of functional impairments the patient has. Imaging is really more confirmatory of neuropsych testing data; it can't tell you specifically what the person's impairments are.

 

[Faebinder]

A CT or MRI only shows structural abnormalities, however, and there is a lot that can be going wrong cognitively that won't be seen in a picture of the brain. A PET scan or fMRI can show areas where the brain isn't functioning. But like Whopper said, standard of practice includes neuropsychological testing which will give you fairly detailed, objective data of where the problems are and what kind of functional impairments the patient has. Imaging is really more confirmatory of neuropsych testing data; it can't tell you specifically what the person's impairments are.

Unfortunately, PET and fMRI are pretty much never done in some hospitals.. not all hospitals have access to nuclear medicine.

Kugel, I agree with you somewhat... some people wont scan a psychiatric patient's head until the tumor is growing out of it.

 

[whopper]

I remember a case where the patient had the CT scan done, and brain metastasis were found (at ARMC Faebinder).

The patient was pretty out there when we got her on the psyche unit. She reportedly tried to drink urine from her own UDS cup.

She didn't appear like classic psychosis, she looked more like delirium. Turned out she was on a psyche unit from a different hospital in NYC before she showed up to our hospital. I called up that hospital, requested the records, she had pancytopenia. They gave her a bunch of antipsychotics & discharged her.

ER notices the wierd behavior from her, they think she's psychotic. She ended up in the psyche inpatient unit.

Her behavior looked more like delirium.

The real story was she had metastasis to the brain, and this was the cause of her real problem. This was only discovered after the scan...and you know what? Medicine still gave us a fight before they admitted her to the medical floor.

 

[strangeglove]

Unfortunately, PET and fMRI are pretty much never done in some hospitals.. not all hospitals have access to nuclear medicine.

Kugel, I agree with you somewhat... some people wont scan a psychiatric patient's head until the tumor is growing out of it.

PET and fMRI are useless for assessing neural activity associated with cognitive functions in individual subjects, i.e. they have no diagnostic utility. They are useful research tools when applied to groups of subjects. SPECT imaging is one modality that has some utility in individuals, but primarily for looking at differences in resting brain activity (i.e. activity not associated with specific cognitive tasks) that are due primarily to dead neurons, as in Alzheimer disease or other degenerative diseases. Also, fMRI is not a nuclear medicine test. All it requires is an MRI scanner.

 

[Faebinder]

PET and fMRI are useless for assessing neural activity associated with cognitive functions in individual subjects, i.e. they have no diagnostic utility. They are useful research tools when applied to groups of subjects. SPECT imaging is one modality that has some utility in individuals, but primarily for looking at differences in resting brain activity (i.e. activity not associated with specific cognitive tasks) that are due primarily to dead neurons, as in Alzheimer disease or other degenerative diseases. Also, fMRI is not a nuclear medicine test. All it requires is an MRI scanner.

Mmmm... ordering a SPECT will be difficult, just like a PET and I am still unsure of the extra added value to management over an MRI. Thanks for the note on the fMRI, still not doable here.

I don't know.. every time I order the MRI and it comes back negative, I can't help but kick myself for wasting a few thousand dollars.. that's how I feel about it. Even when it comes back with some frontal lobe damage, I am unsure how much it improved my management there.

 

[marie337]

How much does a full neuropsych eval cost compared to a CT? Around here, it usually takes a couple of months to get a neuropsych report. If it's really an acute change it seems that a CT would be beneficial. But, then there's the radiation issue, too.

 

[whopper]

Faebinder, if you're kicking yourself for ordering a scan that ends up negative (and I've been there too), look up the symptoms of Orbitofronal Syndrome.

Its not an official DSM diagnosis, however it is described in several published sources.
http://www.ect.org/effects/lobe.html

IF the person is showing symptoms very similar to the symptoms mentioned in the above source, and has a history of head trauma where the frontal lobes may have been affected--it should be considered.

I just had a patient with the following, down to a tee...

Orbitofrontal syndrome (disinhibited)

Disinhibited, impulsive behavior (pseudopsychopathic)
Inappropriate jocular affect, euphoria
Emotional lability
Poor judgment and insight
Distractibility

She was diagnosed with Bipolar by several, and in fact several psychiatrits even wrote down that her head trauma history was of no significance. She had a prominent scar on her right forehead, and according to her & her guardian, she lost consciousness after she was hit on the head, and had very marked changes in personality afterwards.

The lucky thing for me is that I got a neuropsychologist as my right hand lady on the treatment team, so neuropsychological testing was not a problem. I have seen neuropsyche testing done at ARMC though the few cases I've seen it done IMHO weren't justified, and the doc was just fishing.

Even without the neuropsyche testing I was convinced most of her symptoms were not a result of "real" Bipolar and that there were symptoms 2ndary to traumatic brain injury. Another tip off was she had almost no benefit from lithium.

 

[Tradewind]

I order an MRI of the brain and EEG for new onset psychosis without complication by substance abuse. For first onset of mania, if there are psychotic symptoms present that are fairly typical for mania, I may not order an MRI and EEG. If there is anything bizarre, I will order MRI and EEG. Although the results are usually negative, I think it's worth it to the patient, who may be starting to face a lifetime diagnosis of Schizophrenia.

 

[finished]

One illness that can cause both psychosis and cognitive decline is Hashimoto's Encephalopathy. Right now it is not well known, unfortunately. It's diagnosed by thyroid antibodies in the appropriate clinical setting. Most patients are biochemically euthyroid at the time of diagnosis. It's also known as SREAT (steroid responsive encephalopathy associated with autoimmune thyroiditis) and is treated with steroids. Though some patients may have subtle abnormalities on MRI, most have normal neuroimaging studies.