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CURRENT PATHOLOGY IMAGING GUIDELINES

CONTENTS

A. Neck and thorax

B. Upper abdomen

C. Genitourinary system

D. Vascular system

E. Central nervous system

Imaging resources

Problem management

  1. New appearing headache, non migrainous, particularly in older or HIV+ patients; headache with neurologic signs
  2. Headache, sudden severe or suspicion of acute intracranial vascular event (first hours), head trauma
  3. Neurological syndrome, inaugural or non responding epilepsy
  4. Senile or presenile dementia
  5. Acute non postural vertigo, ataxia
  6. Vertigo +/- sensorineural deafness, non pulsatile tinnitus
  7. Conductive deafness
  8. Pulsatile tinnitus
  9. Nose and sinuses
  10. Orbits
  11. Pituitary gland

F. Spine

G. Extremities

H. Nuclear Medicine

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IMAGING RESOURCES

skull plain film front view, lateral view, Towne

  • head trauma (only when CT not available)
  • foreign body localisation
  • cranial vault analysis (Paget disease, myeloma, etc.)

paranasal sinus

  • standard anterior view (Water's projection): facial trauma (orbits, sinus, zygomata), sinusitis confirmation
  • nose-forehead view (Caldwell's projection): frontal and etmoidal sinuses
  • lateral, axial (Hirz) views: additional views, less useful
  • nose lateral projection (in addition to Water's view): trauma

Schuller

  • mastoid bone pneumatisation
  • temporo-mandibular joint
  • special views (Stenvers, straight PA petrous ridges into the orbits, tomographic views, sella, etc.): replaced by CT-scan and MRI

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mandible

  • oblique view: mandible lesion, submaxillary gland calculi, sialography
  • panoramic radiograph: mandible and maxillary bone lesions, dentition survey

MRI

  • first choice examination for any intracranial disease, except head trauma and haemorrhage in acute situations
  • necessary for tumor work-up and white matter diseases
  • early detection of ischemic brain lesions
  • posterior fossa lesions (brain stem, cerebellopontine angle, inner ear)
  • very sensitive for sinus inflammatory disease, but less accurate than CT-scan for preoperative work-up of paranasal sinus (bony architecture)
  • local extension work-up of facial region neoplasia
  • head and neck vascular diseases (MR angiography)
  • functional MRI (perfusion, diffusion, spectroscopy)

Claustrophobia, obese patients, children: these problems are commonly overcome in an open system, with adequate sedation if necessary

CT-scan

  • cranial trauma (brain lesions, cranial base, facial bones)
  • suspicion of haemorrhage (subarachnoidal, subdural, intraparenchymatous)
  • less accurate than MRI, particularly for posterior fossa, white matter disease and brain tumors
  • paranasal sinuses work-up (infectious or inflammatory disorders, neoplasic bone destruction)
  • petrous bone analysis (bony structures and middle ear with ossicles), other cranial basis bone structures
  • precerebral arteries (CT angiography)

ultrasound

  • transfontanellar US: first step investigation of brain in neonates until 6 months old
  • Doppler of intracranial and precerebral arteries (adults)

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PROBLEM MANAGEMENT

1. Headache, new appearing, nonmigrainous, particularly in > 50 years old or AIDS patients, or headache with neurologic signs

  • MRI (eventually CT) to exclude intracranial mass effect or posterior sinusitis
  • (plain x-rays: abandoned)

2. Headache, severe and sudden or suspicion of acute cerebral vascular event (first hours), head trauma

  • CT-scan: subarachnoidal haemorrhage, parenchymatous haemorrhage contra-indicating fibrinolysis, arterial or veinous branch thrombosis, early ischemic signs, perfusion CT
  • MRI: diffusion and perfusion weighted images to detect brain ischemia and to delimit its extension
  • MR angiography: aneurysm, arteriovenous malformation, dural fistule, arterial spasm,, veinous or arterial thrombosis
  • brain angiography (diagnostic & interventional)

3. Neurological syndrome, inaugural or badly responding older epilepsy

  • MRI: multiple sclerosis (MS), tumor, abscess, encephalitis, vascular disease, malformation, hippocampal sclerosis (epilepsy), etc.
  • CT-scan: haemorrhage, trauma

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4. Senile, presenile dementia

  • MRI (calm patients): normal pressure hydrocephalus, neurodegenerative and vascular brain diseases, vasculitis, encephalitis, chronic subdural haematoma, tumors
  • CT (restless patients): brain atrophy, hydrocephalus, ischemic encephalomalacia, intracranial haematoma
  • nuclear medicine

5. Acute non postural vertigo, ataxia

  • MRI: brain stem, cerebellum lesion, vertebrobasilar insufficiency or thrombosis, vertebral artery dissection, vestibular neuronitis, Ménière's disease
  • CT angiography: vertebrobasilar insufficiency or thrombosis, vertebral artery dissection
  • Doppler US: neck vessels

6. Vertigo +/- sensorineural hearing loss, non pulsatile tinnitus

  • MRI: labyrinthitis, VIIIth cranial nerve schwannoma, toxic lesion, Ménière's, MS
  • CT-scan: trauma (petrous bone fracture), inner ear malformations

7. Conductive hearing loss

  • CT-scan (petrous bone thin sections): ossicular chain lesions, middle ear inflammation, otosclerosis, cholesteatoma, trauma
  • IRM: intracranial tumoral (or cholesteatomatous) extension imaging

8. Pulsatile tinnitus

  • MRI or CT-scan: jugular or tympanic glomus tumor, hemangioma, vascular malformation, idiopathic intracranial hypertension

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9. Sinus and nasal cavities

  • CT-scan (transverse sections + coronal reformatting): trauma, complicated acute infections, chronic sinusitis, sinus ostia obstruction, bony malformation, polyposis, tumors
  • MRI: local extension work-up of facial region neoplasia

10. Orbits

  • MRI: tumors, inflammations, optic nerve neuritis, thyroid ophtalmopathy
  • CT-scan: infections (of sinus origin), tumors (bone erosion, calcification), trauma, malformations

11. Pituitary gland

  • MRI: hormonal disorders (acromegaly, hyperprolactinemia, Cushing), signs of optic chiasma compression (adenoma, cyst, craniopharyngioma, meningioma), pituitary apoplexia
  • CT-scan: no MRI available; after MRI for evaluation of bone destruction. NB: microadenomas may easily be missed by CT.

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Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018

References:

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