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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 New appearing headache, non migrainous, particularly in older or HIV+ patients; headache with neurologic signs Headache, sudden severe or suspicion of acute intracranial vascular event (first hours), head trauma Neurological syndrome, inaugural or non responding epilepsy Senile or presenile dementia Acute non postural vertigo, ataxia Vertigo +/- sensorineural deafness, non pulsatile tinnitus Conductive deafness Pulsatile tinnitus Nose and sinuses Orbits Pituitary gland F. Spine G. Extremities H. Nuclear Medicine 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 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) 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 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 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. Pierre Bénédict, MD, FMH radiologist, Lausanne, 1997-2018 References: Guide du bon usage de la SFR ACR (American College of Radiology) guidelines Radiation protection 118: Referral guidelines for imaging (Office for official publications of the European Communities)