Thread by @TWDFNR

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Why is the routine use of neuroimaging for hospitalized patients with delirium a #TWDFNR?

This #tweetorial is a supplement to the review published in the July 2019 issue of the @JHospMedicine

journalofhospitalmedicine.com/jhospmed/artic…

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To understand why the routine use CT/MRI to evaluate delirium is a #TWDFNR, we must first recognize that many acute neurologic processes assessed with neuroimaging DO cause delirium.

Example:

💥13%-48% of patients with acute stroke have delirium💥

journals.sagepub.com/doi/10.1111/j.…

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Regarding neuroimaging in hospitalized patients with delirium, the authors of the #TWDFNR review cover four studies and note that the overall diagnostic yield is 2.7%-14.5%.

How do these values inform your interpretation of the utility of CT/MRI in this setting?

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Given that the findings on CT/MRI are often high stakes (e.g., subdural hematoma or metastases), I see these values as suggesting imaging has value.

But, the 2.7%-14.5% range includes patients with more clear indications for imaging (e.g., recent fall).

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If one excludes clearer indications for CT/MRI...

➢ focal neurologic deficit
➢ new decline in mental status
➢ anticoagulation
➢ recent fall

...the yield falls to 0%-1.5%.

How do these values inform your interpretation of the utility of neuroimaging in this setting?

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The authors argue that:

"While a rate of 1.5% may appear high for a serious outcome such as stroke or intracranial bleeding, it is comparable to rates reported for missed major cardiac events in clinical algorithms for evaluating chest pain."

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They also note that there are additional downsides to routinely obtaining neuroimaging in this setting, including:

➢ cost
➢ radiation exposure
➢ incidental findings

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What do you think?

Given a yield of 0%-1.5%, along with the potential downsides, is routinely obtaining neuroimaging in undifferentiated hospitalized patients with delirium a #TWDFNR?

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Before closing, here are the full recommendations offered by the authors of the #TWDFNR review.

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To read more about this topic, download the Open Access article using the link below.

And, as always, if there are things you think are #TWDFNR, send us an email: [e-mail]

…files-live.s3.us-east-2.amazonaws.com/files/s3fs-pub…