When to suspect masses or hematomas sufficiently to warrant an image:
For an abnormal neuro exam, get an immediate CT to R/O a bleed or herniation. MRI can come next as necessary.
Mental status changes may be the only finding, and may be subtle. When testing orientation, be sure your patient knows the year. If anything in the visit seems weird, do some formal cognition tests like serial-7s, 3’s, or even count backwards by ones!
Consider an image in the “headache” patient with any red flags:
- Occur daily and have progressed in severity;
- Are associated with daily nausea / vomiting;
- A softer clue for tumors: worsen with valsalvas or bending forward. Contrary to popular thought, early morning exacerbation is not a feature of brain tumors.
- Elderly patients, & anyone taking anticoagulants, can have occult subdural hematomas, caused by the most minor of traumas.
- People over 50 with a completely new headache are more likely to have tumors.
See posting Acute Headache – 2.