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0562/SAH/1112/SAH
MRI Imaging of GP Medicare Eligible Conditions
By Dr. Andrew Stuart
Radiologist
Sydney Adventist Hospital
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Learning Objectives
• Indications for GP referred Medicare eligible MRI scans
• MRI imaging appearances of selected cases
• Benefits to patients in being able to access rebatable MRI
• Precautions and contraindications with MRI referral
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Criteria for GP referred for Medicare eligible MRI scans
• MRI Head for unexplained Seizure(s) or Chronic
Headaches
• MRI Cervical Spine for Cervical Radiculopathy or Trauma
• MRI Knee for Acute Knee Trauma with possible Meniscal
Tear or Anterior Cruciate Tear
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ABSOLUTE CONTRA-INDICATIONS FOR MRI
• Pacemaker or defribillator wires (now a pacemaker that is MRI safe)
• Metallic FB`s in the eye
• Swan-Ganz catheter
• Deep brain stimulator
• Bullets or gunshots pellets near great vessels or vital organs
• Cerebral aneurysm clips if magnetic (includes unknown)
• Cochlear implant
• Magnetic dental implant
• Drug infusion devices
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RELATIVE CONTRAINDICATIONS FOR MRI
• AAA stent
• stapes implant
• implanted drug infusion device
• neuro or bone growth stimulator
• surgical clips, wire sutures, screws or mesh
• ocular prosthesis
• penile prosthesis
• joint replacement or prosthesis
• other implants, in particular mechanical devices
• too large patient
• claustrophic patient
• inability to lie still
• surgery in previous 6 weeks
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Nephrogenic systemic fibrosis (NSF)
• Rare and serious condition involving fibrosis of skin, eyes, joints and internal organs.
• Occurs in patients exposed to gadolinium with severe renal disease.
• Please ensure if you are referring a patient for MRI who has suspected renal disease or who is elderly that there is a relatively recent creatinine.
• At the SAN we use Gadovist which has not had a definite case of NSF associated with its use.
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28 yr old female
• Suspected cervical trauma playing netball p/w
left sided neck pain
• Probable migraine
• Exclude spinal pathology
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Sagittal water sensitive MRI sequences T2 STIR
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TOF MRA of neck arteries
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Axial T1 fat saturation
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Axial diffusion scan (DWI)
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Take home points:
• Diagnosis = Lt vertebral artery dissection
with small embolic acute infarct
• Should have started with cervical spine X-
ray
• Need to have a high index of suspicion for
carotid or vertebral dissection
• CT angiogram has better spatial resolution
than MR angiogram but radiation dose
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66 yr male p/w focal epilepsy and increasing cognitive
problems
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Axial susceptibility weighted imaging
(SWI)
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Axial FLAIR Coronal
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Take home points:
• Diagnosis = Cerebral amyloid angiopathy
• Any new onset epilepsy needs investigation
• CAA is common in the demented elderly
normotensive pt.
• MRI susceptibilty imaging is needed to detect these
multifocal microhaemorrhages ( CT occult )
• Amyloid angiopathy is a common cause of
spontaneous lobar haemorrhage in elderly
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35 yr old female p/w severe headache in upright
position
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Coronal Imaging through posterior cranial fossa
FLAIR Susceptibilty weighted image
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Sagittal water sensitive sequences
T2 STIR
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Take home points:
• Diagnosis = Intracranial hypotension
• MRI (SWI) is good for detecting subtle
haemorrhage- new and old
• CT is good for acute haemorrhage only
• Often need to image brain and spine as
pathology is inter-related
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38 yr female p/w common migraine over past
few years better during pregnancy and
lactation. Any vascular or pituitary abnormality?
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T1 post gadolinium
Sagittal Coronal
s
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Coronal SWI (susceptibility image)
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Coronal T2 FLAIR Axial
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MRV performed 4/12 later
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Take home points:
• Diagnosis = Dural sinus thrombosis
• Venous thrombosis progresses to venous infarction in
50% cases
• Venous infarction is eliptogenic and is associated with
headache, papilloedema and neurological deficits
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50 yr female old p/w long standing migraines. Acute
onset drowsiness. Cerebral sinus thrombosis ?
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TOF MR Venogram
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Take home points:
• Diagnosis = uncertain but probably vasculopathy
associated with migraine
• T2 FLAIR hyperintense foci are a common finding
> 60 yrs
• Felt usually to reflect chronic small vessel
ischaemic change associated with ageing
• Significance controversial and findings non
specific although associated with increased risk
of CVA
• In the younger patient the differential includes
vasculitis, demyelination, vasculopathy, migraine
• ? perivascular demyelination around
arteriosclerotic vessels ? myelin pallor with
dilated perivascular spaces ? small lacunar
infarcts
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26 yr old male p/w headache
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Sagittal T2(top) and T1 (below)
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Take home points:
• Diagnosis = Chiari type 1 malformation
• MRI good for sagittal plane, anatomical detail
at skull base as well as syrinx evaluation
• Fundamental problem is underdevelopment
of posterior cranial fossa
• Numerous symptoms including subocciptal
headache
• Usually present in 2nd and 3rd decade
• Treatment controversial – do not usually
intervene if asymptomatic unless syrinx
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16 yr old male p/w locking knee
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Sagittal PD fat sat Coronal PD fat sat
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Axial PD fat sat Coronal PD
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Take home points:
• Diagnosis = bucket handle meniscal tear
• Displaced meniscal fragment resembles
the handle of a bucket
• Pain/locking after single traumatic event
• Requires surgical intervention
• Locking associated with a meniscal tear
indicates a displaced meniscal fragment
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17 yr old female p/w acute knee injury with
instability episode. ? ACL.
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ACL injury occurs when the femur and tibia rotate in opposite
directions under full body weight
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Normal knee Ruptured ACL with anterior tibial translation
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Avulsed intercondylar notch Segond fracture
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Take home points:
• Injury usually caused by pivot shift mechanism
• Associated meniscal tears common
• Posterolateral corner injury associated with marked
instability
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24 yr old female p/w severe neck pain after fall
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Axial CT through C1 and C2
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Sagittal CT reconstructions though Cervical
spine
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Sagittal T2 weighted scan through cervical spine
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Coronal Stir and Axial T2
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MRA of carotid and vertebral arteries in neck
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Take home points:
• Usually perform X-Ray first
• CT performed next if X-ray normal but still
clinical concern or if fracture and need to
define
• MRI normally has role to define soft tissue
injury including vascular injury
• MRI is not a substitute for CT in suspected
cervical spine fracture
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43 yr male present with left cervical radiculopathy
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Sagittal T2 Sagittal T1
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Oblique sagittal T2 Axial T2 at C5/6
level
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Take home points:
• MRI best way to asses for cervical foraminal
stenosis (oblique sagittal T2)
• History should if possible give nerve root
level based on clinical examination
• A CT guided perineural steroid injection can
be performed to relieve symptoms
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Diagnostics GP Conference
Tuesday 18th March 2014
SYDNEY ADVENTIST HOSPITAL
PRESENTS
SPEAKERS
Dr Ross Bradbury – Antibiotic
Therapy for GPs: An Update
Dr David McHarg – Overview of
PET-CT
Dr Andrew Stuart – MRI Imaging of
Conditions that are Medicare
Eligible for GP Referral
CONVENOR
Dr James Cheatham