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Examples of red-flag symptoms in the older adult include but are not limited to pain following a fall or other trauma, fever, sudden unexplained weight loss, acute onset of severe pain, new-onset weakness or sensory loss, loss of bowel or bladder function, jaw claudication, new headaches, bone pain in a patient with a ...

sciencedirect.com - Red Flag Symptom - an overview | ScienceDirect Topics

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16.1.3.3 Imaging Studies

There is a consensus that a brain MRI is not routinely necessary in patients with suspected FHA.2 The latter should be performed where there are red flag symptoms indicating a brain mass (i.e., severe headaches, problems with vision, symptoms of increased intracranial pressure), if there is history of brain trauma preceding the development of symptoms, or when no precipitating factor can be elicited despite a detailed clinical history and physical examination. An MRI should also be performed when there is clinical and/or biochemical evidence of hyperprolactinemia, acromegaly, and/or hypercortisolism, or changes in thirst and urination suggestive of diabetes insipidus. Signs of hypopituitarism in the hormonal workup can prompt a pituitary MRI, although clinicians should remember that FHA could be accompanied by functional disturbances of the hypothalamic-pituitary-thyroid (HPT) axis, which mimic central hypothyroidism.38 Finally, brain imaging could be considered in cases with persistent HH despite adequate treatment or moderation of the external trigger, although the actual likelihood of a significant finding on MRI in this context has never been studied. A bone mineral density (BMD) scan by dual X-ray absorptiometry (DXA) is indicated for women with 6 or more months of amenorrhea or a long-standing history of irregular menses, especially in the presence of an eating disorder, low BMI, or both. It is important to stress that bone impairment in these patients is not solely the reflection of increased bone resorption due to hypoestrogenism, but includes also a reduction of bone formation in both weight-loss and exercise-induced FHA.39,40 This is probably due to the associated relative hypercortisolism and other endocrine alterations that contribute to the chronic hypercatabolic state. More important, a higher risk of fracture has been shown in FHA women with both eating disorders41 and excessive exercise,25,42 thus justifying early screening by DXA. As expected, there is a preferential loss of BMD at the lumbar spine (a trabecular-rich site), as in other forms of hypogonadal osteoporosis. Although the available evidence points toward a deterioration of bone quality (microarchitecture) in addition to bone quantity (BMD),43,44 the use of tools assessing bone structure, such as high-resolution peripheral quantitative computed tomography (CT), is not widespread in clinical practice. Specific data on bone morbidity of women with stress-induced FHA are lacking, but screening these women with DXA seems reasonable given the known deleterious effects of hypoestrogenism. Clinicians should be aware that the same DXA scan can provide data about body composition, including lean and adipose tissue mass. This can be informative, especially in exercise-induced FHA.

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