Appropriateness criteria headache-UPR

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Appropriateness criteria headache-UPR

  1. 1. Headaches: An Evidence Based Imaging Approach Jorge A Vidal, MD Adjunct Professor of Radiology Edgar Colon Negron, MD Director Diagnostic Radiology UPR-RCM
  2. 2. Imaging Modalities <ul><li>Computed Tomography (CT)
  3. 3. Magnetic Resonance Imaging (MRI)
  4. 4. Digital Substraction Angiography (DSA)
  5. 5. Positron Emission Tomography (PET)
  6. 6. Single Positron Emission Computed Tomography (SPECT)
  7. 7. Ultrasound (US)
  8. 8. Radiographs </li></ul>
  9. 9. Imaging Modalities <ul><li>Computed Tomography (CT)
  10. 10. Magnetic Resonance Imaging (MRI)
  11. 11. Digital Substraction Angiography (DSA)
  12. 12. Positron Emission Tomography (PET)
  13. 13. Single Positron Emission Computed Tomography (SPECT)
  14. 14. Ultrasound (US)
  15. 15. Radiographs </li></ul>
  16. 16. CT <ul><li>Benefits </li></ul><ul><ul><li>Higher spatial resolution than MRI
  17. 17. Excellent at showing life-threatening pathology </li></ul></ul><ul><ul><ul><li>Hemorrhage, Hydrocephalus
  18. 18. Space-occupying lesions
  19. 19. MDCT can do angiography
  20. 20. FAST!!! </li></ul></ul><li>Limitations </li><ul><li>Lower contrast-resolution than MRI
  21. 21. HIGH RADIATION DOSE
  22. 22. Costly $$, but lower than MRI </li></ul></ul>
  23. 23. Subdural Hematoma
  24. 24. MRI <ul><li>Benefits </li></ul><ul><ul><li>Higher contrast resolution than CT
  25. 25. Excellent at showing anatomy and pathology </li></ul></ul><ul><ul><ul><li>Hemorrhage, Hydrocephalus, Space occupying lesions
  26. 26. Infections, inflammatory processes
  27. 27. Physiologic information (Spectroscopy)
  28. 28. Usually “last stop shop” – final answer… </li></ul></ul><li>Limitations </li><ul><li>Lower spatial-resolution than CT
  29. 29. Costly $$$
  30. 30. Long imaging time </li></ul></ul>
  31. 31. Aneurysms
  32. 32. MR Spectroscopy
  33. 33. MRI <ul><li>Contraindications </li></ul><ul><ul><li>Pacemakers and defibrillator devices
  34. 34. Loose metal fragments in the orbits </li></ul><li>Relative contraindications </li><ul><li>Metal in body (depends if it is ferromagnetic)
  35. 35. Surgical implants </li></ul></ul><ul><ul><ul><li>Most are MRI compatible depending of magnet’s field strength </li></ul></ul></ul>
  36. 36. DSA <ul><li>Excellent modality for evaluation of the arterial and venous system </li></ul><ul><ul><li>Can be diagnostic and therapeutic
  37. 37. High radiation dose
  38. 38. Invasive </li></ul></ul><ul><ul><ul><li>Higher risks </li></ul><li>Mostly relegated to therapeutic use today or for problem-solving </li></ul></ul>
  39. 39. PET-CT and SPECT <ul><li>Excellent modality for evaluation of the brain physiology </li></ul><ul><ul><li>Brain death studies
  40. 40. Epilepsy studies
  41. 41. Cancer and other tumors
  42. 42. HIGH RADIATION DOSE </li></ul></ul>
  43. 43. Ultrasound <ul><li>Used mostly for vascular evaluation in patients with SAH </li></ul><ul><ul><li>Monitoring of intracranial arterial velocities </li></ul></ul>
  44. 44. Radiographs There is NO appropriate reason for the use of skull films for the evaluation of headaches!
  45. 45. I have a headache! <ul><li>Questions to ask the patient </li></ul><ul><ul><li>How long?
  46. 46. How strong? </li></ul></ul><ul><ul><ul><li>Is it similar to previous episodes? </li></ul><li>Immune status or pre-existing medical conditions (i.e. HTN, Sickle cell anemia)
  47. 47. Pregnant?
  48. 48. History of cancer, rapid weight loss?
  49. 49. Neurological deficits or new symptoms?
  50. 50. Recent travel destinations? </li></ul></ul>
  51. 52. Thunderclap Headache <ul><li>Sudden, severe headache
  52. 53. “ Worst headache of my life”
  53. 54. In some studies up to 47% had a Subarachnoid hemorrhage. </li></ul>
  54. 56. Subarachnoid Hemorrhage
  55. 57. Aneurysm
  56. 58. Severe Unilateral Headache <ul><li>In young patients be alert for pain radiating to the neck
  57. 59. Neurological symptoms </li></ul><ul><ul><li>Horner syndrome
  58. 60. Stroke-like symptoms </li></ul><li>Be suspicious for carotid or vertebral artery dissection </li></ul>
  59. 62. CTA and MRA
  60. 63. Temporal Headache <ul><li>Patients older than 55 years old
  61. 64. New-onset headache in temple region
  62. 65. Tender superficial temporal artery
  63. 66. Temporal arteritis </li></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><ul><li>Avoid blindness or brainstem strokes </li></ul></ul></ul>
  64. 67. Temporal Arteritis Copyright © 2007 by the American Roentgen Ray Society Bley, T. A. et al. Am. J. Roentgenol. 2005;184:283-287
  65. 68. Pregnant Patients <ul><li>Must have caution with Radiation Dose
  66. 69. Assess for neurological symptoms </li></ul>
  67. 71. Hydrocephalus
  68. 73. Extra-axial Mass
  69. 74. Extra-axial Mass
  70. 75. Sellar Mass
  71. 77. Lymphoma
  72. 78. Lymphoma
  73. 80. Toxoplasmosis
  74. 81. Take Home Points <ul><li>Screening patients with isolated, nontraumatic headache by means of CT or MRI is usually not warranted, but may depend on clinical circumstances. </li></ul><ul><ul><li>These procedures may be more likely to be positive in certain at risk populations. </li></ul></ul>
  75. 82. Take Home Points <ul><li>Patients with suspected meningitis or pregnant patients may pose diagnostic challenges.
  76. 83. HIV+, cancer patients and other at risk populations </li></ul><ul><ul><li>Should be screened when presenting with a new onset headache </li></ul></ul>
  77. 84. Take Home Points <ul><li>RADIATION SAFETY </li></ul><ul><ul><li>Please remember that CT is a high-radiation modality </li></ul></ul><ul><ul><ul><li>Children
  78. 85. Pregnant patients
  79. 86. Retina </li></ul></ul></ul>
  80. 87. References <ul><li>American College of Radiology Appropriateness Criteria for Headache </li></ul><ul><ul><li>www.acr.org/ac </li></ul><li>MRI Safety </li><ul><li>www.mrisafety.com </li></ul></ul>

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