Mental status changes

Q1: What are the common intra cranial causes for mental status changes?

• Acute
  • Infectious
    • Meningitis (bacterial, TB, syphilitic, viral, fungal)
    • HSV encephalitis
    • AIDS
    • Parasitic infections
  • Vascular
    • Hypertensive encephalopathy
    • Vertebrobasilar ischemia
    • Right (non dominant) hemispheric infarct
  • Subarachnoid hemorrhage
  • SLE, DIC, TTP
  • Trauma
    • Concussion
    • Intra cranial hemorrhage
  • Seizure
    • Postictal
    • Complex partial
      
• Chronic
  • Dementia
    • Alzheimer's Disease (by far #1)
    • Dementia with Lewy bodies
    • Vascular (multi-infarct) dementia
    • Pick's disease
  • Brain tumor, meningeal neoplasia
  • Trauma
    • Chronic subdural hematoma

Q2: Which of these would benefit from imaging procedures?

• Most may benefit from either CT or MRI.
• Alzheimer's disease-MR/CT often show cortical atrophy and enlarged ventricles but this is commonly seen in non demented elderly
• Pick's disease-CT and MR show +/- frontal/anterior temporal lobe atrophy but this is NOT diagnostic (Pick's is a postmortem diagnosis)

Mental status changes-Cases

Case1:

A 20 year old Type I diabetic male has a period of weakness, polyuria, and polydipsia, followed by mental status changes.  You discover that he has not taken his insulin as scheduled.  Labs show serum glucose of 600 and high anion gap metabolic acidosis.  Urine tests show glycosuria and ketonuria.

• Are imaging procedures necessary for this patient?  If so, what would you order?
  • No
• What is your diagnosis?
  • Diabetic ketoacidosis

Case 2:.

A 70-year-old male is in minor car accident in which he thinks he might have bumped his head.  A few weeks later he develops a mild but constant headache followed by bouts of confusion.

• Are imaging procedures necessary for this patient?  If so, what would you order?
  • Yes. He should get a CT of the head first to rule out an acute bleed. If normal, this should be followed up with a MRI.
• What is your diagnosis?
  • Sub acute subdural hematoma

Case 3:

40-year old lady with a history of breast carcinoma diagnosed 6 years ago, presented with headache, ataxia. progressive memory problems and changes in her personality.

• Are imaging procedures necessary for this patient?  If so, what would you order?
  • If this patient's condition were severe and presented to the ER, a CT would likely be performed first.
  • If he presented to the outpatient clinic with a sub acute presentation, a MRI, the study of choice for her probable condition.
• What is your diagnosis?
  • Brain metastases.

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