ACR Appropriateness Criteria Acute Mental Status Change, Delirium, and New Onset Psychosis


Michael D. Luttrull, The Ohio State University Wexner Medical Center, Columbus, Ohio. Electronic address: mluttrull@gmail.com.
Daniel J. Boulter, Research Author, The Ohio State University Wexner Medical Center, Columbus, Ohio.
Claudia F. Kirsch, Panel Chair, Northwell Health, Zucker Hofstra School of Medicine at Northwell, Manhasset, New York.
Joseph M. Aulino, Vanderbilt University Medical Center, Nashville, Tennessee.
Joshua S. Broder, Duke University School of Medicine, Durham, North Carolina; American College of Emergency Physicians.
Santanu Chakraborty, Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada.
Asim F. Choudhri, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee.
Andrew F. Ducruet, Barrow Neurological Institute, Phoenix, Arizona; neurosurgical consultant.Follow
A Tuba Kendi, Mayo Clinic, Rochester, Minnesota.
Ryan K. Lee, Einstein Healthcare Network, Philadelphia, Pennsylvania.
David S. Liebeskind, University of California Los Angeles, Los Angeles, California; American Academy of Neurology.
William Mack, University of Southern California, Los Angeles, California; neurosurgical consultant.
Toshio Moritani, University of Michigan, Ann Arbor, Michigan.
Robert P. Roca, Sheppard Pratt Health System, Towson, Maryland; American Psychiatric Association.
Lubdha M. Shah, University of Utah, Salt Lake City, Utah.
Aseem Sharma, Mallinckrodt Institute of Radiology, Saint Louis, Missouri.
Robert Y. Shih, Walter Reed National Military Medical Center, Bethesda, Maryland.
Sophia C. Symko, Neuroradiology Consultant, Denver, Colorado.
Julie Bykowski, Specialty Chair, UC San Diego Health Center, San Diego, California.

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Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.


AUC, Altered mental status, Appropriate Use Criteria, Appropriateness Criteria, Confusion, Delirium, Neuroimaging, Psychotic disorders

Medical Subject Headings

Brain Diseases (diagnostic imaging); Contrast Media; Delirium (diagnostic imaging); Diagnosis, Differential; Evidence-Based Medicine; Humans; Neuroimaging (methods); Psychotic Disorders (diagnostic imaging); Societies, Medical; United States

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Journal of the American College of Radiology : JACR







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