Download - Appropriateness criteria headache-UPR
Headaches: An Evidence Based Imaging Approach
Jorge A Vidal, MDAdjunct Professor of RadiologyEdgar Colon Negron, MDDirector Diagnostic RadiologyUPR-RCM
Imaging Modalities
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Digital Substraction Angiography (DSA)
Positron Emission Tomography (PET)
Single Positron Emission Computed Tomography (SPECT)
Ultrasound (US)
Radiographs
Imaging Modalities
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Digital Substraction Angiography (DSA)
Positron Emission Tomography (PET)
Single Positron Emission Computed Tomography (SPECT)
Ultrasound (US)
Radiographs
CT
Benefits
Higher spatial resolution than MRI
Excellent at showing life-threatening pathology
Hemorrhage, Hydrocephalus
Space-occupying lesions
MDCT can do angiography
FAST!!!
LimitationsLower contrast-resolution than MRI
HIGH RADIATION DOSE
Costly $$, but lower than MRI
Subdural Hematoma
MRI
Benefits
Higher contrast resolution than CT
Excellent at showing anatomy and pathology
Hemorrhage, Hydrocephalus, Space occupying lesions
Infections, inflammatory processes
Physiologic information (Spectroscopy)
Usually last stop shop final answer
LimitationsLower spatial-resolution than CT
Costly $$$
Long imaging time
Aneurysms
MR Spectroscopy
MRI
Contraindications
Pacemakers and defibrillator devices
Loose metal fragments in the orbits
Relative contraindicationsMetal in body (depends if it is ferromagnetic)
Surgical implants
Most are MRI compatible depending of magnets field strength
DSA
Excellent modality for evaluation of the arterial and venous system
Can be diagnostic and therapeutic
High radiation dose
Invasive
Higher risks
Mostly relegated to therapeutic use today or for problem-solving
PET-CT and SPECT
Excellent modality for evaluation of the brain physiology
Brain death studies
Epilepsy studies
Cancer and other tumors
HIGH RADIATION DOSE
Ultrasound
Used mostly for vascular evaluation in patients with SAH
Monitoring of intracranial arterial velocities
Radiographs
There is NO appropriate reason for the use of skull films for the evaluation of headaches!
I have a headache!
Questions to ask the patient
How long?
How strong?
Is it similar to previous episodes?
Immune status or pre-existing medical conditions (i.e. HTN, Sickle cell anemia)
Pregnant?
History of cancer, rapid weight loss?
Neurological deficits or new symptoms?
Recent travel destinations?
Thunderclap Headache
Sudden, severe headache
Worst headache of my life
In some studies up to 47% had a Subarachnoid hemorrhage.
Subarachnoid Hemorrhage
Aneurysm
Severe Unilateral Headache
In young patients be alert for pain radiating to the neck
Neurological symptoms
Horner syndrome
Stroke-like symptoms
Be suspicious for carotid or vertebral artery dissection
CTA and MRA
Temporal Headache
Patients older than 55 years old
New-onset headache in temple region
Tender superficial temporal artery
Temporal arteritis
Steroids
Avoid blindness or brainstem strokes
Copyright 2007 by the American Roentgen Ray SocietyBley, T. A. et al. Am. J. Roentgenol. 2005;184:283-287Temporal Arteritis
Pregnant Patients
Must have caution with Radiation Dose
Assess for neurological symptoms
Hydrocephalus
Extra-axial Mass
Extra-axial Mass
Sellar Mass
Lymphoma
Lymphoma
Toxoplasmosis
Take Home Points
Screening patients with isolated, nontraumatic headache by means of CT or MRI is usually not warranted, but may depend on clinical circumstances.
These procedures may be more likely to be positive in certain at risk populations.
Take Home Points
Patients with suspected meningitis or pregnant patients may pose diagnostic challenges.
HIV+, cancer patients and other at risk populations
Should be screened when presenting with a new onset headache
Take Home Points
RADIATION SAFETY
Please remember that CT is a high-radiation modality
Children
Pregnant patients
Retina
References
American College of Radiology Appropriateness Criteria for Headache
www.acr.org/ac
MRI Safetywww.mrisafety.com
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