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acrac_69489_3 | Acute Pyelonephritis | CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases. MR urography (MRU) is also tailored to improve imaging of the urinary system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for the evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory phase. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2- weighted images of the urinary tract. OR Discussion of Procedures by Variant Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging. CT Abdomen and Pelvis CT of the abdomen and pelvis is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [1,10,14,15]. CT imaging may be useful if symptoms persist for 72 hours [8,10,14,16]. Nearly 95% of patients with uncomplicated pyelonephritis become afebrile within 48 hours after appropriate antibiotic therapy, and nearly 100% become afebrile within 72 hours [8,14]. | Acute Pyelonephritis. CT abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts and without both the precontrast and excretory phases. MR urography (MRU) is also tailored to improve imaging of the urinary system. Unenhanced MRU relies upon heavily T2-weighted imaging of the intrinsic high signal intensity from urine for the evaluation of the urinary tract. IV contrast is administered to provide additional information regarding obstruction, urothelial thickening, focal lesions, and stones. A contrast-enhanced T1-weighted series should include corticomedullary, nephrographic, and excretory phase. Thin-slice acquisition and multiplanar imaging should be obtained. For the purposes of this document, we make a distinction between MRU and MRI abdomen and pelvis without and with IV contrast. MRI abdomen and pelvis without and with IV contrast is defined as any protocol not specifically tailored for evaluation of the upper and lower urinary tracts, without both the precontrast and excretory phases, and without heavily T2- weighted images of the urinary tract. OR Discussion of Procedures by Variant Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging. CT Abdomen and Pelvis CT of the abdomen and pelvis is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [1,10,14,15]. CT imaging may be useful if symptoms persist for 72 hours [8,10,14,16]. Nearly 95% of patients with uncomplicated pyelonephritis become afebrile within 48 hours after appropriate antibiotic therapy, and nearly 100% become afebrile within 72 hours [8,14]. | 69489 |
acrac_69489_4 | Acute Pyelonephritis | CT Abdomen CT of the abdomen is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [1,10,14,15]. CTU CTU is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [1,10,14,15]. Acute Pyelonephritis Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Fluoroscopy Voiding Cystourethrography Fluoroscopy voiding cystourethrography (VCUG) is not beneficial in the initial imaging evaluation for the first- time presentation of suspected APN in an uncomplicated patient [15]. MRI Abdomen and Pelvis MRI of the abdomen and pelvis is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. MRI Abdomen MRI of the abdomen is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. MRU MRU of the abdomen and pelvis is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis (KUB) is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Radiography Intravenous Urography Intravenous urography (IVU) is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. US Abdomen Ultrasound (US) of the abdomen is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. In addition, US had inferior accuracy for detection of APN compared with CT [10,17]. | Acute Pyelonephritis. CT Abdomen CT of the abdomen is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [1,10,14,15]. CTU CTU is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [1,10,14,15]. Acute Pyelonephritis Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Fluoroscopy Voiding Cystourethrography Fluoroscopy voiding cystourethrography (VCUG) is not beneficial in the initial imaging evaluation for the first- time presentation of suspected APN in an uncomplicated patient [15]. MRI Abdomen and Pelvis MRI of the abdomen and pelvis is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. MRI Abdomen MRI of the abdomen is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. MRU MRU of the abdomen and pelvis is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis (KUB) is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Radiography Intravenous Urography Intravenous urography (IVU) is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. US Abdomen Ultrasound (US) of the abdomen is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. In addition, US had inferior accuracy for detection of APN compared with CT [10,17]. | 69489 |
acrac_69489_5 | Acute Pyelonephritis | US Color Doppler Kidneys and Bladder Retroperitoneal US color doppler of the kidneys, bladder, and retroperitoneum is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Variant 2 : Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, adv anced ag e, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging. The goal of imaging in a complicated patient with suspected APN is to identify the presence or absence of APN and identify associated complications. Patients with a history of renal calculi are separately discussed in variant 3. CT Abdomen and Pelvis There is widespread agreement that CT of the abdomen and pelvis with IV contrast is a useful study to diagnose APN in a complicated patient without a prior history of stone disease [1,8,14-21]. CT imaging should include the pelvis for multiple reasons. For example, unsuspected urolithiasis can be in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites can be identified, and abnormalities of the urinary bladder can be detected, among other potential sources of APN. Contrast-enhanced CT can be used to detect signs of APN including focal or multifocal decreased parenchymal enhancement, complications of APN including a renal or perirenal abscess or emphysematous pyelonephritis, and underlying problems including hydronephrosis, obstructing stones, or congenital abnormalities [1,8,14,17-19]. In a retrospective study of patients with suspected APN that underwent both unenhanced and contrast-enhanced CT (n = 183), contrast-enhanced CT detected parenchymal inv olvement in 62.5% of patients, whereas unenhanced CT detected parenchymal involvement in only 1.4% of cases, and 4.6% of patients had renal abscesses that were missed on unenhanced CT and on ly detected on contrast-e nhanced CT [19] . Furthermore, un enhanced CT missed the | Acute Pyelonephritis. US Color Doppler Kidneys and Bladder Retroperitoneal US color doppler of the kidneys, bladder, and retroperitoneum is not beneficial in the initial imaging evaluation for the first-time presentation of suspected APN in an uncomplicated patient [15]. Variant 2 : Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, adv anced ag e, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging. The goal of imaging in a complicated patient with suspected APN is to identify the presence or absence of APN and identify associated complications. Patients with a history of renal calculi are separately discussed in variant 3. CT Abdomen and Pelvis There is widespread agreement that CT of the abdomen and pelvis with IV contrast is a useful study to diagnose APN in a complicated patient without a prior history of stone disease [1,8,14-21]. CT imaging should include the pelvis for multiple reasons. For example, unsuspected urolithiasis can be in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites can be identified, and abnormalities of the urinary bladder can be detected, among other potential sources of APN. Contrast-enhanced CT can be used to detect signs of APN including focal or multifocal decreased parenchymal enhancement, complications of APN including a renal or perirenal abscess or emphysematous pyelonephritis, and underlying problems including hydronephrosis, obstructing stones, or congenital abnormalities [1,8,14,17-19]. In a retrospective study of patients with suspected APN that underwent both unenhanced and contrast-enhanced CT (n = 183), contrast-enhanced CT detected parenchymal inv olvement in 62.5% of patients, whereas unenhanced CT detected parenchymal involvement in only 1.4% of cases, and 4.6% of patients had renal abscesses that were missed on unenhanced CT and on ly detected on contrast-e nhanced CT [19] . Furthermore, un enhanced CT missed the | 69489 |
acrac_69489_6 | Acute Pyelonephritis | Acute Pyelonephritis diagnosis of acute extrarenal conditions including cholecystitis (n = 1), liver abscess (n = 1), and appendicitis (n =1), which were all subsequently diagnosed with contrast-enhanced CT [19]. In the absence of a history of renal stones, the benefit of performing unenhanced CT in combination with contrast- enhanced CT is negligible in a complicated patient with suspected APN. In a small retrospective study of adult patients with clinical and laboratory suspicion of APN who all underwent triphasic abdominal CT (n = 100), the accuracy of the nephrographic phase among 2 readers for diagnosis of APN was 90% to 92% and for diagnosis of urolithiasis was 96% to 99% [22]. There was no significant difference in the accuracy of the triphasic abdominal CT relative to the nephrographic phase only [22]. In a prospective nonrandomized data collection study of patients with a final diagnosis of APN (n = 827), the detection rate of APN was 84.4% (445/527) by abdominal CT and only 40% (72/180) by abdominal US [10]. Although the detection rate of urolithiasis and hydronephrosis were similar by abdominal CT and abdominal US, the rate of detection of renal abscess was 4.0% (21/527) by abdominal CT and only 1.1% (2/180) by US [10]. US, CT, and MRI can show evidence of chronic pyelonephritis, including renal scarring, atrophy and cortical thinning, hypertrophy of residual normal tissue, and renal asymmetry [1,8,14,15,17,19,20]. Advantages of abdominal CT and US over abdominal MRI may include superior detection of urolithiasis, and CT may be superior to US and MRI in detection of gas in emphysematous pyelonephritis [1,14,15,18]. Contrast-enhanced CT of the abdomen and pelvis is supported in high-risk or complicated patients if initial treatment is unresponsive or symptoms worsen [1,2,8,10,15,17-19]. In general, contrast-enhanced CT of the abdomen and pelvis should be delayed 72 hours after initiation of therapy [1,8,14-21]. | Acute Pyelonephritis. Acute Pyelonephritis diagnosis of acute extrarenal conditions including cholecystitis (n = 1), liver abscess (n = 1), and appendicitis (n =1), which were all subsequently diagnosed with contrast-enhanced CT [19]. In the absence of a history of renal stones, the benefit of performing unenhanced CT in combination with contrast- enhanced CT is negligible in a complicated patient with suspected APN. In a small retrospective study of adult patients with clinical and laboratory suspicion of APN who all underwent triphasic abdominal CT (n = 100), the accuracy of the nephrographic phase among 2 readers for diagnosis of APN was 90% to 92% and for diagnosis of urolithiasis was 96% to 99% [22]. There was no significant difference in the accuracy of the triphasic abdominal CT relative to the nephrographic phase only [22]. In a prospective nonrandomized data collection study of patients with a final diagnosis of APN (n = 827), the detection rate of APN was 84.4% (445/527) by abdominal CT and only 40% (72/180) by abdominal US [10]. Although the detection rate of urolithiasis and hydronephrosis were similar by abdominal CT and abdominal US, the rate of detection of renal abscess was 4.0% (21/527) by abdominal CT and only 1.1% (2/180) by US [10]. US, CT, and MRI can show evidence of chronic pyelonephritis, including renal scarring, atrophy and cortical thinning, hypertrophy of residual normal tissue, and renal asymmetry [1,8,14,15,17,19,20]. Advantages of abdominal CT and US over abdominal MRI may include superior detection of urolithiasis, and CT may be superior to US and MRI in detection of gas in emphysematous pyelonephritis [1,14,15,18]. Contrast-enhanced CT of the abdomen and pelvis is supported in high-risk or complicated patients if initial treatment is unresponsive or symptoms worsen [1,2,8,10,15,17-19]. In general, contrast-enhanced CT of the abdomen and pelvis should be delayed 72 hours after initiation of therapy [1,8,14-21]. | 69489 |
acrac_69489_7 | Acute Pyelonephritis | CT Abdomen CT of the abdomen with IV contrast has high accuracy for the diagnosis of APN in a complicated patient but does not allow for a comprehensive assessment of the entire genitourinary tract [1,8,14-21]. CT imaging should include the pelvis to detect potential pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. CTU CTU There is insufficient evidence to support the use of CTU for detection of suspected APN in the complicated patient. There is variability in CTU imaging technique. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to detection and characterization of APN in a complicated patient. DMSA Renal Scan According to the literature, renal scintigraphy, specifically Tc-99m DMSA scan, is not beneficial for the diagnosis of APN in adults. In contrast, renal scintigraphy is useful in the pediatric population where there is difficulty in differentiating lower UTI from APN [23]. However, differentiation of lower UTI from APN is less problematic in adults, and pediatric vesicoureteral reflux often resolves in adulthood. Furthermore, in a small prospective study of adult patients with UTIs who underwent both contrast-enhanced CT and DMSA (n = 36), CT had higher accuracy in diagnosis of APN [24]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a complicated adult patient [15]. Fluoroscopy Voiding Cystourethrography VCUG is commonly used to identify vesicoureteral reflux but is not beneficial in the acute setting. VCUG is usually performed after resolution of acute symptoms to assess for an underlying anatomic or congenital cause, particularly in children with recurrent febrile UTIs [25]. | Acute Pyelonephritis. CT Abdomen CT of the abdomen with IV contrast has high accuracy for the diagnosis of APN in a complicated patient but does not allow for a comprehensive assessment of the entire genitourinary tract [1,8,14-21]. CT imaging should include the pelvis to detect potential pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. CTU CTU There is insufficient evidence to support the use of CTU for detection of suspected APN in the complicated patient. There is variability in CTU imaging technique. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to detection and characterization of APN in a complicated patient. DMSA Renal Scan According to the literature, renal scintigraphy, specifically Tc-99m DMSA scan, is not beneficial for the diagnosis of APN in adults. In contrast, renal scintigraphy is useful in the pediatric population where there is difficulty in differentiating lower UTI from APN [23]. However, differentiation of lower UTI from APN is less problematic in adults, and pediatric vesicoureteral reflux often resolves in adulthood. Furthermore, in a small prospective study of adult patients with UTIs who underwent both contrast-enhanced CT and DMSA (n = 36), CT had higher accuracy in diagnosis of APN [24]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a complicated adult patient [15]. Fluoroscopy Voiding Cystourethrography VCUG is commonly used to identify vesicoureteral reflux but is not beneficial in the acute setting. VCUG is usually performed after resolution of acute symptoms to assess for an underlying anatomic or congenital cause, particularly in children with recurrent febrile UTIs [25]. | 69489 |
acrac_69489_8 | Acute Pyelonephritis | Adult women with predisposing factors suspicious for vesicoureteral reflux may also benefit from VCUG [26]. However, VCUG is likely of limited benefit in the acute setting. MRI Abdomen and Pelvis MRI of the abdomen without or with IV contrast may be useful for detecting and characterizing congenital anomalies of the kidneys, and imaging of the pelvis could improve detection of congenital abnormalities of the distal ureters and abnormalities of the urinary bladder. In general, MRI of the pelvis is usually not combined with MRI of the abdomen unless an MRU is being performed. Diffusion-weighted imaging (DWI) [20] and contrast- Acute Pyelonephritis enhanced MRI have similar benefits in detecting renal abnormalities [27]. Studies in adults have shown that DWI can be useful in the diagnosis of uncomplicated pyelonephritis [28-30]. APN, renal abscesses, and pyonephrosis have lower apparent diffusion coefficient (ADC) values than normal renal cortical parenchyma [28]. As such, DWI and ADC provide a viable alternative to contrast-enhanced MRI or CT [30]. Disadvantages of MRI includes relatively poor accuracy for detection of urolithiasis and relatively reduced ability to detect gas in emphysematous py elonephritis [31,32] . Similar to CT, MRI does not provide benefit early in uncomplicated cases [8,14]. MRI Abdomen MRI of the abdomen has high accuracy for the diagnosis of APN in a complicated patient but does not allow for a comprehensive assessment of the entire genitourinary tract. Failure to include the pelvis could lead to a missed opportunity to detect urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal ureteral insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. MRU The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a complicated patient. | Acute Pyelonephritis. Adult women with predisposing factors suspicious for vesicoureteral reflux may also benefit from VCUG [26]. However, VCUG is likely of limited benefit in the acute setting. MRI Abdomen and Pelvis MRI of the abdomen without or with IV contrast may be useful for detecting and characterizing congenital anomalies of the kidneys, and imaging of the pelvis could improve detection of congenital abnormalities of the distal ureters and abnormalities of the urinary bladder. In general, MRI of the pelvis is usually not combined with MRI of the abdomen unless an MRU is being performed. Diffusion-weighted imaging (DWI) [20] and contrast- Acute Pyelonephritis enhanced MRI have similar benefits in detecting renal abnormalities [27]. Studies in adults have shown that DWI can be useful in the diagnosis of uncomplicated pyelonephritis [28-30]. APN, renal abscesses, and pyonephrosis have lower apparent diffusion coefficient (ADC) values than normal renal cortical parenchyma [28]. As such, DWI and ADC provide a viable alternative to contrast-enhanced MRI or CT [30]. Disadvantages of MRI includes relatively poor accuracy for detection of urolithiasis and relatively reduced ability to detect gas in emphysematous py elonephritis [31,32] . Similar to CT, MRI does not provide benefit early in uncomplicated cases [8,14]. MRI Abdomen MRI of the abdomen has high accuracy for the diagnosis of APN in a complicated patient but does not allow for a comprehensive assessment of the entire genitourinary tract. Failure to include the pelvis could lead to a missed opportunity to detect urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal ureteral insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. MRU The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a complicated patient. | 69489 |
acrac_69489_9 | Acute Pyelonephritis | Studies comparing MRU with DMSA renal scintigraphy for the detection of pyelonephritis and renal scaring have shown that MRU without and with IV contrast is at least equivalent or superior to DMSA for this specific purpose [33-35]. No studies of MRU without IV contrast were identified in the literature. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis (KUB) is not beneficial in the imaging evaluation for suspected APN in a complicated adult patient [15]. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a complicated adult patient [15]. US Abdomen Although US of the abdomen has similar accuracy to CT for detection of urolithiasis and hydronephrosis, the main disadvantages of US compared with CT are a lower rate of detection of APN and renal abscess, but it can be performed portably and without IV contrast [10,36-38]. Of note, the sensitivity for detection of acute complicated pyelonephritis and for detection of a renal abscess is higher with contrast-enhanced US relative to unenhanced US [37,38]. In one small retrospective study of adults with APN (n = 100), the accuracy of contrast-enhanced US for detection of APN approached that of contrast-enhanced CT [39]. US Color Doppler Kidneys and Bladder Retroperitoneal US including color Doppler has been shown to increase sensitivity for detection of APN beyond grayscale US [40]. US with power Doppler has been shown to have sensitivities and specificities that approach 90% in children with APN [41,42] and may have similar results in adults. Although US has similar accuracy to CT for detection of urolithiasis and hydronephrosis, the main disadvantages of US compared with CT are a lower rate of detection of APN and renal abscess [10,36-38]. Of note, the sensitivity for detection of acute complicated pyelonep hritis and for detection of a renal abscess is higher with contrast- enhanced US relative to unenhanced US [37,38]. Variant 3: Suspected acute pyelonephritis. | Acute Pyelonephritis. Studies comparing MRU with DMSA renal scintigraphy for the detection of pyelonephritis and renal scaring have shown that MRU without and with IV contrast is at least equivalent or superior to DMSA for this specific purpose [33-35]. No studies of MRU without IV contrast were identified in the literature. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis (KUB) is not beneficial in the imaging evaluation for suspected APN in a complicated adult patient [15]. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a complicated adult patient [15]. US Abdomen Although US of the abdomen has similar accuracy to CT for detection of urolithiasis and hydronephrosis, the main disadvantages of US compared with CT are a lower rate of detection of APN and renal abscess, but it can be performed portably and without IV contrast [10,36-38]. Of note, the sensitivity for detection of acute complicated pyelonephritis and for detection of a renal abscess is higher with contrast-enhanced US relative to unenhanced US [37,38]. In one small retrospective study of adults with APN (n = 100), the accuracy of contrast-enhanced US for detection of APN approached that of contrast-enhanced CT [39]. US Color Doppler Kidneys and Bladder Retroperitoneal US including color Doppler has been shown to increase sensitivity for detection of APN beyond grayscale US [40]. US with power Doppler has been shown to have sensitivities and specificities that approach 90% in children with APN [41,42] and may have similar results in adults. Although US has similar accuracy to CT for detection of urolithiasis and hydronephrosis, the main disadvantages of US compared with CT are a lower rate of detection of APN and renal abscess [10,36-38]. Of note, the sensitivity for detection of acute complicated pyelonep hritis and for detection of a renal abscess is higher with contrast- enhanced US relative to unenhanced US [37,38]. Variant 3: Suspected acute pyelonephritis. | 69489 |
acrac_69489_10 | Acute Pyelonephritis | History of renal stones or renal obstruction. Initial imaging. CT Abdomen and Pelvis Renal stones or renal obstruction can be a source of APN [1,8,11,15,18,19]. CT of the abdomen and pelvis is highly sensitive for detection of stones and hydronephrosis [8,11]. Furthermore, CT is a useful imaging study to diagnose APN if symptoms persist or worsen after 72 hours have passed [1,8,14-21]. CT imaging should include the pelvis to identify stones in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters, and abnormalities of the urinary bladder, among other potential sources of APN. Both unenhanced and contrast-enhanced CT are able to detect urolithiasis, perinephric fluid, renal swelling, and hydronephrosis [1,8,14,17-19]. However, contrast-e nhanced CT has been shown to improve detection of APN parenchymal changes, a renal abscess, and extrarenal acute conditions that may clinical present as suspicious for APN [19]. Of note, unenhanced CT has higher sensitivity than contrast-enhanced CT for detection of small renal calculi. Acute Pyelonephritis In a prospective nonrandomized data collection study of patients with a final diagnosis of APN (n = 827), the detection rate of APN was 84.4% (445/527) by abdominal CT and only 40% (72/180) by abdominal US [10]. Although the detection rate of urolithiasis and hydronephrosis were similar by abdominal CT and abdominal US, the rate of detection of renal abscess was 4.0% (21/527) by abdominal CT and only 1.1% (2/180) by US [10]. CT and US have similar detection rates for renal stones and hydronephrosis. Advantages of abdominal CT and US over abdominal MRI may include superior detection of small urothelial stones [1,14,15,18]. In a small retrospective study of adult patients with clinical and laboratory suspicion of APN who all underwent triphasic abdominal CT (n = 100), the accuracy of the nephrographic phase among 2 readers for diagnosis of APN was 90% to 92% and for diagnosis of urolithiasis was 96% to 99% [22]. | Acute Pyelonephritis. History of renal stones or renal obstruction. Initial imaging. CT Abdomen and Pelvis Renal stones or renal obstruction can be a source of APN [1,8,11,15,18,19]. CT of the abdomen and pelvis is highly sensitive for detection of stones and hydronephrosis [8,11]. Furthermore, CT is a useful imaging study to diagnose APN if symptoms persist or worsen after 72 hours have passed [1,8,14-21]. CT imaging should include the pelvis to identify stones in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters, and abnormalities of the urinary bladder, among other potential sources of APN. Both unenhanced and contrast-enhanced CT are able to detect urolithiasis, perinephric fluid, renal swelling, and hydronephrosis [1,8,14,17-19]. However, contrast-e nhanced CT has been shown to improve detection of APN parenchymal changes, a renal abscess, and extrarenal acute conditions that may clinical present as suspicious for APN [19]. Of note, unenhanced CT has higher sensitivity than contrast-enhanced CT for detection of small renal calculi. Acute Pyelonephritis In a prospective nonrandomized data collection study of patients with a final diagnosis of APN (n = 827), the detection rate of APN was 84.4% (445/527) by abdominal CT and only 40% (72/180) by abdominal US [10]. Although the detection rate of urolithiasis and hydronephrosis were similar by abdominal CT and abdominal US, the rate of detection of renal abscess was 4.0% (21/527) by abdominal CT and only 1.1% (2/180) by US [10]. CT and US have similar detection rates for renal stones and hydronephrosis. Advantages of abdominal CT and US over abdominal MRI may include superior detection of small urothelial stones [1,14,15,18]. In a small retrospective study of adult patients with clinical and laboratory suspicion of APN who all underwent triphasic abdominal CT (n = 100), the accuracy of the nephrographic phase among 2 readers for diagnosis of APN was 90% to 92% and for diagnosis of urolithiasis was 96% to 99% [22]. | 69489 |
acrac_69489_11 | Acute Pyelonephritis | There was no significant difference in the accuracy of the triphasic abdominal CT relative to nephrographic phase alone [22]. Thereby, detection of urothelial stones is similar with unenhanced and contrast-enhanced CT. CT Abdomen CT of the abdomen without IV contrast has high accuracy for detection or renal stones, and CT of the abdomen with IV contrast has high accuracy for the diagnosis of APN. However, CT of the abdomen alone does not allow for a comprehensive assessment of the entire genitourinary tract [1,8,14-21]. CT imaging should include the pelvis to detect potential pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. CTU CTU There is insufficient evidence to support the use of CTU for detection of suspected APN in the complicated patient. There is variability in the CTU imaging technique. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to detection and characterization of APN in a complicated patient. DMSA Renal Scan CT may have higher accuracy than DMSA renal scintigraphy for detection of APN and certainly has higher accuracy for detection of stones, which cannot be directly visualized by renal scintigraphy [24]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. Fluoroscopy Voiding Cystourethrography VCUG is not beneficial in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. | Acute Pyelonephritis. There was no significant difference in the accuracy of the triphasic abdominal CT relative to nephrographic phase alone [22]. Thereby, detection of urothelial stones is similar with unenhanced and contrast-enhanced CT. CT Abdomen CT of the abdomen without IV contrast has high accuracy for detection or renal stones, and CT of the abdomen with IV contrast has high accuracy for the diagnosis of APN. However, CT of the abdomen alone does not allow for a comprehensive assessment of the entire genitourinary tract [1,8,14-21]. CT imaging should include the pelvis to detect potential pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. CTU CTU There is insufficient evidence to support the use of CTU for detection of suspected APN in the complicated patient. There is variability in the CTU imaging technique. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to detection and characterization of APN in a complicated patient. DMSA Renal Scan CT may have higher accuracy than DMSA renal scintigraphy for detection of APN and certainly has higher accuracy for detection of stones, which cannot be directly visualized by renal scintigraphy [24]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. Fluoroscopy Voiding Cystourethrography VCUG is not beneficial in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. | 69489 |
acrac_69489_12 | Acute Pyelonephritis | MRI Abdomen and Pelvis MRI of the abdomen and pelvis can be useful for detecting APN, scarring, congenital anomalies of the kidneys, renal abscesses, hydronephrosis, and pyonephrosis [28-30], and imaging of the pelvis could improve detection of stones in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters, and abnormalities of the urinary bladder, among other potential sources of APN. However, MRI has poor accuracy for the detection of small urothelial calculi [31,32]. Other disadvantages of MRI includes its relatively reduced ability to detect gas in emphysematous pyelonephritis [31,32]. Similar to CT, MRI is not beneficial early in uncomplicated cases [8,14]. MRI Abdomen MRI of the abdomen has high accuracy for the diagnosis of APN in a complicated patient but does not allow for a comprehensive assessment of the entire genitourinary tract. Failure to include the pelvis could lead to a missed opportunity to detect urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal ureteral insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. MRI has poor accuracy for the detection of small urothelial calculi. Another disadvantage of MRI includes its relatively reduced ability to detect gas in emphysematous pyelonephritis [31,32]. MRU The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a complicated patient. Furthermore, MRU has poor accuracy for the detection of small urothelial calculi Acute Pyelonephritis [31,32]. In a small prospective study comparing CTU with MRU in adult patients referred from the emergency department for evaluation of renal colic or hematuria (n = 70), all cases of urinary stones were detected by CTU (100%) versus 79% of cases detected by MRU [43]. Another disadvantage of MRU includes its relatively reduced ability to detect gas in emphysematous pyelonephritis [31,32]. | Acute Pyelonephritis. MRI Abdomen and Pelvis MRI of the abdomen and pelvis can be useful for detecting APN, scarring, congenital anomalies of the kidneys, renal abscesses, hydronephrosis, and pyonephrosis [28-30], and imaging of the pelvis could improve detection of stones in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters, and abnormalities of the urinary bladder, among other potential sources of APN. However, MRI has poor accuracy for the detection of small urothelial calculi [31,32]. Other disadvantages of MRI includes its relatively reduced ability to detect gas in emphysematous pyelonephritis [31,32]. Similar to CT, MRI is not beneficial early in uncomplicated cases [8,14]. MRI Abdomen MRI of the abdomen has high accuracy for the diagnosis of APN in a complicated patient but does not allow for a comprehensive assessment of the entire genitourinary tract. Failure to include the pelvis could lead to a missed opportunity to detect urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal ureteral insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. MRI has poor accuracy for the detection of small urothelial calculi. Another disadvantage of MRI includes its relatively reduced ability to detect gas in emphysematous pyelonephritis [31,32]. MRU The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a complicated patient. Furthermore, MRU has poor accuracy for the detection of small urothelial calculi Acute Pyelonephritis [31,32]. In a small prospective study comparing CTU with MRU in adult patients referred from the emergency department for evaluation of renal colic or hematuria (n = 70), all cases of urinary stones were detected by CTU (100%) versus 79% of cases detected by MRU [43]. Another disadvantage of MRU includes its relatively reduced ability to detect gas in emphysematous pyelonephritis [31,32]. | 69489 |
acrac_69489_13 | Acute Pyelonephritis | Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis (KUB) has limited utility in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. Although radiography of the abdomen and pelvis could detect large calculi, it cannot detect APN. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. US Abdomen US of the kidneys has nearly 100% sensitivity for detection of large stones (>5 mm) and hydronephrosis, although the accuracy for detection of small stones (<3 mm) is poor [44,45]. Some disadvantages of US compared with CT are a lower rate of detection of APN and renal abscess [10,36-38]. Of note, the sensitivity for detection of acute complicated pyelonephritis and for detection of a renal abscess is higher with contrast-enhanced US relative to unenhanced US [37,38]. In one small retrospective study of adults with APN (n = 100), the accuracy of contrast-enhanced US for detection o f APN approached that of contrast- enhanced CT [39]. US Color Doppler Kidneys and Bladder Retroperitoneal US of the kidneys has nearly 100% sensitivity for detection of large stones (>5 mm) and hydronephrosis, although the accuracy for detection of small stones (<3 mm) is poor [44,45]. Use of color Doppler has been shown to increase sensitivity for detection of APN in adults and children [40-42]. Inclusion of the bladder could identify other abnormalities contributing to APN. A disadvantage of US compared with CT is a lower rate of detection of APN and renal abscess [10,36-38]. Variant 4: Suspected acute pyelonephritis. Pregnant patient with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging. | Acute Pyelonephritis. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis (KUB) has limited utility in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. Although radiography of the abdomen and pelvis could detect large calculi, it cannot detect APN. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a patient with a history of renal stones or renal obstruction [15]. US Abdomen US of the kidneys has nearly 100% sensitivity for detection of large stones (>5 mm) and hydronephrosis, although the accuracy for detection of small stones (<3 mm) is poor [44,45]. Some disadvantages of US compared with CT are a lower rate of detection of APN and renal abscess [10,36-38]. Of note, the sensitivity for detection of acute complicated pyelonephritis and for detection of a renal abscess is higher with contrast-enhanced US relative to unenhanced US [37,38]. In one small retrospective study of adults with APN (n = 100), the accuracy of contrast-enhanced US for detection o f APN approached that of contrast- enhanced CT [39]. US Color Doppler Kidneys and Bladder Retroperitoneal US of the kidneys has nearly 100% sensitivity for detection of large stones (>5 mm) and hydronephrosis, although the accuracy for detection of small stones (<3 mm) is poor [44,45]. Use of color Doppler has been shown to increase sensitivity for detection of APN in adults and children [40-42]. Inclusion of the bladder could identify other abnormalities contributing to APN. A disadvantage of US compared with CT is a lower rate of detection of APN and renal abscess [10,36-38]. Variant 4: Suspected acute pyelonephritis. Pregnant patient with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging. | 69489 |
acrac_69489_14 | Acute Pyelonephritis | CT Abdomen and Pelvis There is no current literature specific to the use of CT of the abdomen and pelvis in the evaluation of suspected APN in pregnant patients. CT imaging of the abdomen and pelvis is not supported as the initial imaging in pregnant patients. The main disadvantage of using CT of the abdomen and pelvis in a pregnant patient is the risk of ionizing radiation to the embryo or fetus and the mother, particularly for the pelvic portion of the examination [46]. CT Abdomen There is no current literature to support the use of CT of the abdomen in the evaluation of suspected APN in pregnant patients. CT imaging of the abdomen does not allow for detection of pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. CTU CTU There is no current literature to support the use of CTU in the evaluation of suspected APN in pregnant patients. There is variability in CTU imaging technique. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to the detection and characterization of APN in a pregnant patient. A CTU protocol that does not include unenhanced imaging and that uses a split bolus to achieve a mixed nephrographic and excretory phase could mask the presence of urolithiasis. DMSA Renal Scan DMSA renal scintigraphy is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. Acute Pyelonephritis Fluoroscopy Voiding Cystourethrography VCUG is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. | Acute Pyelonephritis. CT Abdomen and Pelvis There is no current literature specific to the use of CT of the abdomen and pelvis in the evaluation of suspected APN in pregnant patients. CT imaging of the abdomen and pelvis is not supported as the initial imaging in pregnant patients. The main disadvantage of using CT of the abdomen and pelvis in a pregnant patient is the risk of ionizing radiation to the embryo or fetus and the mother, particularly for the pelvic portion of the examination [46]. CT Abdomen There is no current literature to support the use of CT of the abdomen in the evaluation of suspected APN in pregnant patients. CT imaging of the abdomen does not allow for detection of pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. CTU CTU There is no current literature to support the use of CTU in the evaluation of suspected APN in pregnant patients. There is variability in CTU imaging technique. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to the detection and characterization of APN in a pregnant patient. A CTU protocol that does not include unenhanced imaging and that uses a split bolus to achieve a mixed nephrographic and excretory phase could mask the presence of urolithiasis. DMSA Renal Scan DMSA renal scintigraphy is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. Acute Pyelonephritis Fluoroscopy Voiding Cystourethrography VCUG is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. | 69489 |
acrac_69489_15 | Acute Pyelonephritis | MRI Abdomen and Pelvis There is no current literature specific to the use of MRI of the abdomen and pelvis in the evaluation of suspected APN in pregnant patients. MRI of the abdomen and pelvis is generally safe in pregnant patients and may be useful in certain situations. MRI does do not expose the embryo, or fetus, or pregnant mother to ionizing radiation and can be useful for detecting APN, scarring, congenital anomalies of the kidneys, renal abscesses, hydronephrosis, and pyonephrosis [28-30]. Although there are no known adverse effects to human fetuses and no known cases of nephrogenic systemic fibrosis linked to the use of clinical doses of gadolinium-based contrast agents (GBCAs) in pregnant patients, GBCAs should only be used if the indication is considered critical and the potential benefits justify the potential unknown risk to the fetus [47]. MRI of the abdomen can be useful for detecting APN, scarring, congenital anomalies of the kidneys, renal abscesses, hydronephrosis, and pyonephrosis [28-30]. DWI [20] and contrast-enhanced MRI have similar benefits in detecting renal abnormalities [27] . Stud ies in adults have shown that DWI can be useful in the diagnosis of pyelonephritis [28-30]. APN, renal abscesses, and pyonephrosis have lower ADC values than normal renal cortical parenchyma [28]. Inclusion of the pelvis could improve detection of abnormalities of the lower urinary tract. MRI may allow for a limited evaluation of the embryo or fetus. However, traditional MRI examinations do n ot provide a comprehensive assessment of the urinary collecting systems [8,31,32]. The main disadvantages of MRI are poor accuracy for the detection of small urothelial calculi and reduced accuracy for detection of emphysematous pyelonephritis, [31,32]. MRI Abdomen There is no current literature specific to the use of MRI of the abdomen in the evaluation of suspected APN in pregnant patients. | Acute Pyelonephritis. MRI Abdomen and Pelvis There is no current literature specific to the use of MRI of the abdomen and pelvis in the evaluation of suspected APN in pregnant patients. MRI of the abdomen and pelvis is generally safe in pregnant patients and may be useful in certain situations. MRI does do not expose the embryo, or fetus, or pregnant mother to ionizing radiation and can be useful for detecting APN, scarring, congenital anomalies of the kidneys, renal abscesses, hydronephrosis, and pyonephrosis [28-30]. Although there are no known adverse effects to human fetuses and no known cases of nephrogenic systemic fibrosis linked to the use of clinical doses of gadolinium-based contrast agents (GBCAs) in pregnant patients, GBCAs should only be used if the indication is considered critical and the potential benefits justify the potential unknown risk to the fetus [47]. MRI of the abdomen can be useful for detecting APN, scarring, congenital anomalies of the kidneys, renal abscesses, hydronephrosis, and pyonephrosis [28-30]. DWI [20] and contrast-enhanced MRI have similar benefits in detecting renal abnormalities [27] . Stud ies in adults have shown that DWI can be useful in the diagnosis of pyelonephritis [28-30]. APN, renal abscesses, and pyonephrosis have lower ADC values than normal renal cortical parenchyma [28]. Inclusion of the pelvis could improve detection of abnormalities of the lower urinary tract. MRI may allow for a limited evaluation of the embryo or fetus. However, traditional MRI examinations do n ot provide a comprehensive assessment of the urinary collecting systems [8,31,32]. The main disadvantages of MRI are poor accuracy for the detection of small urothelial calculi and reduced accuracy for detection of emphysematous pyelonephritis, [31,32]. MRI Abdomen There is no current literature specific to the use of MRI of the abdomen in the evaluation of suspected APN in pregnant patients. | 69489 |
acrac_69489_16 | Acute Pyelonephritis | MRI of the abdomen does not allow for detection of pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. MRI of the abdomen is generally safe in pregnant patients and may be useful in certain situations [28-30]. Although there are no known adverse effects to human fetuses and no known cases of nephrogenic systemic fibrosis linked to the use of clinical doses of GBCAs in pregnant patients, GBCAs should only be used if the indication is considered critical and the potential benefits justify the potential unknown risk to the fetus [47]. MRI of the abdomen may allow for a limited evaluation of the embryo or fetus, although most fetuses would not be included in the field of view. The main disadvantages of MRI are poor accuracy for the detection of small urothelial calculi and reduced accuracy for detection of emphysematous pyelonephritis [31,32]. MRU There is no current literature specific to the use of MRU without IV contrast in the evaluation of suspected APN in pregnant patients. The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a pregnant patient. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. US Abdomen There is no current literature specific to the use of US of the abdomen in the evaluation of suspected APN in pregnant patients. Pregnancy increases the risk of complications from APN, although poor obstetrical outcomes are rare [48]. US of the abdomen may be used to detect complications of APN. | Acute Pyelonephritis. MRI of the abdomen does not allow for detection of pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. MRI of the abdomen is generally safe in pregnant patients and may be useful in certain situations [28-30]. Although there are no known adverse effects to human fetuses and no known cases of nephrogenic systemic fibrosis linked to the use of clinical doses of GBCAs in pregnant patients, GBCAs should only be used if the indication is considered critical and the potential benefits justify the potential unknown risk to the fetus [47]. MRI of the abdomen may allow for a limited evaluation of the embryo or fetus, although most fetuses would not be included in the field of view. The main disadvantages of MRI are poor accuracy for the detection of small urothelial calculi and reduced accuracy for detection of emphysematous pyelonephritis [31,32]. MRU There is no current literature specific to the use of MRU without IV contrast in the evaluation of suspected APN in pregnant patients. The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a pregnant patient. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a pregnant patient [15]. US Abdomen There is no current literature specific to the use of US of the abdomen in the evaluation of suspected APN in pregnant patients. Pregnancy increases the risk of complications from APN, although poor obstetrical outcomes are rare [48]. US of the abdomen may be used to detect complications of APN. | 69489 |
acrac_69489_17 | Acute Pyelonephritis | US of the abdomen is safe in pregnancy and is rapid and portable and does not require the use of contrast material [8]. US is often used as a screening examination in pregnancy, is sensitive and specific test for diagnosing hydronephrosis, and does not expose the patient or fetus to ionizing radiation [49,50]. Acute Pyelonephritis Physiologic hydronephrosis of pregnancy occurs in >80% of pregnant patients in the second and third trimester; therefore, hydronephrosis alone is not a reliable sign of APN in pregnant patients [51]. Furthermore, US has a low detection rate of APN and renal abscess [10,36-38]. US Color Doppler Kidneys and Bladder Retroperitoneal There is no current literature specific to the use of US color Doppler of the kidneys, bladder, and retroperitoneum in the evaluation of suspected APN in pregnant patients. US of the kidney, ureters, and bladder is safe in pregnancy, is rapid and portable, and does not require the use of contrast material [8]. US is often used as a screening examination in pregnancy, is sensitive and specific test for diagnosing hydronephrosis, and does not expose the patient or fetus to ionizing radiation [49,50]. Use of color Doppler has been shown to increase sensitivity for detection of APN compared to US with grayscale imaging [40-42]. Physiologic hydronephrosis of pregnancy occurs in >80% of pregnant patients in the second and third trimester; therefore, hydronephrosis alone is not a reliable sign of APN in pregnant patients [51]. Furthermore, US has a lower detection rate of APN and renal abscess than CT [10,36-38]. Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging. Some local practice patterns do not routinely give IV contrast agents to patients with renal transplants. | Acute Pyelonephritis. US of the abdomen is safe in pregnancy and is rapid and portable and does not require the use of contrast material [8]. US is often used as a screening examination in pregnancy, is sensitive and specific test for diagnosing hydronephrosis, and does not expose the patient or fetus to ionizing radiation [49,50]. Acute Pyelonephritis Physiologic hydronephrosis of pregnancy occurs in >80% of pregnant patients in the second and third trimester; therefore, hydronephrosis alone is not a reliable sign of APN in pregnant patients [51]. Furthermore, US has a low detection rate of APN and renal abscess [10,36-38]. US Color Doppler Kidneys and Bladder Retroperitoneal There is no current literature specific to the use of US color Doppler of the kidneys, bladder, and retroperitoneum in the evaluation of suspected APN in pregnant patients. US of the kidney, ureters, and bladder is safe in pregnancy, is rapid and portable, and does not require the use of contrast material [8]. US is often used as a screening examination in pregnancy, is sensitive and specific test for diagnosing hydronephrosis, and does not expose the patient or fetus to ionizing radiation [49,50]. Use of color Doppler has been shown to increase sensitivity for detection of APN compared to US with grayscale imaging [40-42]. Physiologic hydronephrosis of pregnancy occurs in >80% of pregnant patients in the second and third trimester; therefore, hydronephrosis alone is not a reliable sign of APN in pregnant patients [51]. Furthermore, US has a lower detection rate of APN and renal abscess than CT [10,36-38]. Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging. Some local practice patterns do not routinely give IV contrast agents to patients with renal transplants. | 69489 |
acrac_69489_18 | Acute Pyelonephritis | For this variant, we assumed there are no contraindications to IV contrast agents. CT Abdomen and Pelvis There is no current literature specific to the use of CT of the abdomen and pelvis in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. CT of the abdomen and pelvis would include imaging of the native and transplant kidneys, and CT with IV contrast is highly accurate for the diagnose APN in a complicated patient, particularly if symptoms persist or worsen after 72 hours have passed [1,8,14-21]. Both unenhanced and contrast-enhanced CT are able to detect urolithiasis, perinephric fluid, renal swelling, and hydronephrosis [1,8,14,17-19]. Contrast-enhanced CT has been shown to improve detection of APN parenchymal changes, a renal abscess, and extrarenal acute conditions that may clinically present as suspicious for APN. CT imaging of the pelvis can detect potential pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. Of note, unenhanced CT has higher sensitivity than contrast- enhanced CT for detection of small renal calculi. CT Abdomen There is no current literature to support the use of CT of the abdomen in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. APN of a renal allograft is more common than APN of the native kidneys, and renal transplant recipients are at high risk for complications from a variety of factors, including immunosuppression [52]. CT of the abdomen would not include complete imaging of the pelvic transplant kidney(s), which might miss important pathology in the transplant kidney [1,8,14-21]. CTU CTU There is limited information on the benefit of CTU for detection of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. | Acute Pyelonephritis. For this variant, we assumed there are no contraindications to IV contrast agents. CT Abdomen and Pelvis There is no current literature specific to the use of CT of the abdomen and pelvis in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. CT of the abdomen and pelvis would include imaging of the native and transplant kidneys, and CT with IV contrast is highly accurate for the diagnose APN in a complicated patient, particularly if symptoms persist or worsen after 72 hours have passed [1,8,14-21]. Both unenhanced and contrast-enhanced CT are able to detect urolithiasis, perinephric fluid, renal swelling, and hydronephrosis [1,8,14,17-19]. Contrast-enhanced CT has been shown to improve detection of APN parenchymal changes, a renal abscess, and extrarenal acute conditions that may clinically present as suspicious for APN. CT imaging of the pelvis can detect potential pelvic abnormalities including urolithiasis in the distal ureters or urinary bladder, congenital abnormalities of the distal ureters and abnormal insertion sites, and abnormalities of the urinary bladder, among other potential sources of APN. Of note, unenhanced CT has higher sensitivity than contrast- enhanced CT for detection of small renal calculi. CT Abdomen There is no current literature to support the use of CT of the abdomen in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. APN of a renal allograft is more common than APN of the native kidneys, and renal transplant recipients are at high risk for complications from a variety of factors, including immunosuppression [52]. CT of the abdomen would not include complete imaging of the pelvic transplant kidney(s), which might miss important pathology in the transplant kidney [1,8,14-21]. CTU CTU There is limited information on the benefit of CTU for detection of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. | 69489 |
acrac_69489_19 | Acute Pyelonephritis | The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to detection and characterization of APN in this patient cohort. DMSA Renal Scan DMSA renal scintigraphy is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Fluoroscopy Voiding Cystourethrography VCUG is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Acute Pyelonephritis MRI Abdomen and Pelvis There is limited literature on the use of MRI of the abdomen and pelvis in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. APN is rare in native kidneys. However, APN of a renal allograft is more common, and renal transplant recipients are at high risk for complications from a variety of factors, including immunosuppression [52]. In a p rospective study of renal transplant recipients with suspected APN (n = 5 6), contrast-enhanced MRI was positive in 66% (37/56) of patients [53] . In a small retrospective study of 24 kidney transplant recipients who underwent MRI without IV contrast and had clinical suspicion of APN, 9 2% (22/24) of patients had positive findings on MRI, specifically on DWI and ADC images [54]. Studies in ad ult patients without renal transplants hav e shown that DWI can be useful in the diagnosis of uncomplicated pyelonephritis [28-30]. APN, renal abscesses, and pyonephrosis have lower ADC values than normal renal cortical parenchyma [28]. As such, DWI and ADC provide a viable alternative to contrast-enhanced MRI or CT [30]. | Acute Pyelonephritis. The added benefit of an excretory phase from any CTU image acquisition protocol is likely negligible with respect to detection and characterization of APN in this patient cohort. DMSA Renal Scan DMSA renal scintigraphy is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Fluoroscopy Antegrade Pyelography Antegrade pyelography is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Fluoroscopy Voiding Cystourethrography VCUG is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Acute Pyelonephritis MRI Abdomen and Pelvis There is limited literature on the use of MRI of the abdomen and pelvis in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. APN is rare in native kidneys. However, APN of a renal allograft is more common, and renal transplant recipients are at high risk for complications from a variety of factors, including immunosuppression [52]. In a p rospective study of renal transplant recipients with suspected APN (n = 5 6), contrast-enhanced MRI was positive in 66% (37/56) of patients [53] . In a small retrospective study of 24 kidney transplant recipients who underwent MRI without IV contrast and had clinical suspicion of APN, 9 2% (22/24) of patients had positive findings on MRI, specifically on DWI and ADC images [54]. Studies in ad ult patients without renal transplants hav e shown that DWI can be useful in the diagnosis of uncomplicated pyelonephritis [28-30]. APN, renal abscesses, and pyonephrosis have lower ADC values than normal renal cortical parenchyma [28]. As such, DWI and ADC provide a viable alternative to contrast-enhanced MRI or CT [30]. | 69489 |
acrac_69489_20 | Acute Pyelonephritis | The main disadvantages of MRI of the abdomen and pelvis are poor accuracy for the detection of small urothelial calculi and reduced accuracy for detection of emphysematous pyelonephritis, [31,32]. MRI Abdomen There is limited literature on the use of MRI of the abdomen in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. APN is rare in native kidneys, and abdominal imaging would not include complete imaging of the pelvic transplant kidney(s), which would likely miss important pathology in the transplant kidney [1,8,14-21]. MRI Pelvis There is limited literature on the use of MRI of the pelvis in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. Pelvic MRI alone would not include evaluation of the native kidneys. MRI of the abdomen and pelvis would be more comprehensive for identification of the source of the APN. MRU There is no current literature specific to the use of MRU in the evaluation of suspected APN in patients with a pelvic renal transplant and native kidneys in situ. The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a pregnant patient. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. US Abdomen APN is rare in native kidneys. Because an US of the abdomen would not include complete imaging of the pelvic transplant kidney(s), the examination is not likely to diagnose APN [1,8,14-21]. US Color Doppler Kidneys and Bladder Retroperitoneal APN is most commonly an issue with the transplant kidney. | Acute Pyelonephritis. The main disadvantages of MRI of the abdomen and pelvis are poor accuracy for the detection of small urothelial calculi and reduced accuracy for detection of emphysematous pyelonephritis, [31,32]. MRI Abdomen There is limited literature on the use of MRI of the abdomen in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. APN is rare in native kidneys, and abdominal imaging would not include complete imaging of the pelvic transplant kidney(s), which would likely miss important pathology in the transplant kidney [1,8,14-21]. MRI Pelvis There is limited literature on the use of MRI of the pelvis in the evaluation of suspected APN in a patient with a pelvic renal transplant and native kidneys in situ. Pelvic MRI alone would not include evaluation of the native kidneys. MRI of the abdomen and pelvis would be more comprehensive for identification of the source of the APN. MRU There is no current literature specific to the use of MRU in the evaluation of suspected APN in patients with a pelvic renal transplant and native kidneys in situ. The excretory phase of MRU does not confer additional benefit with respect to detection and characterization of APN in a pregnant patient. Radiography Abdomen and Pelvis Radiography of the abdomen and pelvis is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. Radiography Intravenous Urography IVU is not beneficial in the imaging evaluation for suspected APN in a patient with a pelvic renal transplant and native kidneys in situ [15]. US Abdomen APN is rare in native kidneys. Because an US of the abdomen would not include complete imaging of the pelvic transplant kidney(s), the examination is not likely to diagnose APN [1,8,14-21]. US Color Doppler Kidneys and Bladder Retroperitoneal APN is most commonly an issue with the transplant kidney. | 69489 |
acrac_3082590_0 | Blunt Chest Trauma Suspected Cardiac Injury | aUniversity of Michigan Health System, Ann Arbor, Michigan. bPanel Chair, Duke University Medical Center, Durham, North Carolina. cPanel Chair, University of Chicago, Chicago, Illinois. dPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. ePanel Vice-Chair, University of Kansas Medical Center, Kansas City, Kansas. fUniversity of Louisville School of Medicine, Louisville, Kentucky. gStanford University Medical Center, Stanford, California; The Society of Thoracic Surgeons. hUniversity of Southern California, Los Angeles, California. iThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. jKaiser Permanente, Los Angeles, California. kVancouver General Hospital, Vancouver, British Columbia, Canada. lUniversity of Washington, Seattle, Washington. mUniversity of California San Diego, San Diego, California. nHarvard Medical School, Boston, Massachusetts. oNaval Medical Center Portsmouth, Portsmouth, Virginia. pMassachusetts General Hospital, Boston, Massachusetts. qStritch School of Medicine Loyola University Chicago, Maywood, Illinois; Society for Cardiovascular Magnetic Resonance. rDuke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons. sUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. tWisconsin Heart Hospital, Milwaukee, Wisconsin; Nuclear cardiology expert. uDenver Health MC/UPI, Denver, Colorado; American College of Emergency Physicians. vSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. wSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. | Blunt Chest Trauma Suspected Cardiac Injury. aUniversity of Michigan Health System, Ann Arbor, Michigan. bPanel Chair, Duke University Medical Center, Durham, North Carolina. cPanel Chair, University of Chicago, Chicago, Illinois. dPanel Vice-Chair, Massachusetts General Hospital, Boston, Massachusetts. ePanel Vice-Chair, University of Kansas Medical Center, Kansas City, Kansas. fUniversity of Louisville School of Medicine, Louisville, Kentucky. gStanford University Medical Center, Stanford, California; The Society of Thoracic Surgeons. hUniversity of Southern California, Los Angeles, California. iThe University of Chicago Medical Center, Chicago, Illinois; American College of Physicians. jKaiser Permanente, Los Angeles, California. kVancouver General Hospital, Vancouver, British Columbia, Canada. lUniversity of Washington, Seattle, Washington. mUniversity of California San Diego, San Diego, California. nHarvard Medical School, Boston, Massachusetts. oNaval Medical Center Portsmouth, Portsmouth, Virginia. pMassachusetts General Hospital, Boston, Massachusetts. qStritch School of Medicine Loyola University Chicago, Maywood, Illinois; Society for Cardiovascular Magnetic Resonance. rDuke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons. sUniversity of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. tWisconsin Heart Hospital, Milwaukee, Wisconsin; Nuclear cardiology expert. uDenver Health MC/UPI, Denver, Colorado; American College of Emergency Physicians. vSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. wSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. | 3082590 |
acrac_3082590_1 | Blunt Chest Trauma Suspected Cardiac Injury | Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. CTA can also be performed with or without ECG gating. The ECG gating is usually prospective and allows for better assessment of cardiac injuries as well as concomitant aortic injuries in patients with blunt chest trauma and concomitant cardiac injuries. The role of focused assessment with sonography for trauma (FAST) (or extended-FAST or chest abdominal-FAST in evaluating chest injury) is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT [14,15]. Ultrasound (US) may be able to diagnose certain thoracic and abdominal injuries, but it is an insufficient test to fully exclude injuries to these areas because it has a relatively lower specificity compared with CT [16]. Hemodynamic instability and findings such as abnormal ECG and increased level of high-sensitivity troponin in hemodynamically stable patients should raise the suspicion of cardiac injuries, and these patients should undergo rapid cardiac assessment by echocardiography [7,10]. An initial FAST examination can detect pericardial effusion and wall motion abnormality. Hall et al [11] analyzed the cardiac component of the FAST examination in hypotensive (systolic blood pressure <90 mm Hg) and normotensive trauma patients. | Blunt Chest Trauma Suspected Cardiac Injury. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. CTA can also be performed with or without ECG gating. The ECG gating is usually prospective and allows for better assessment of cardiac injuries as well as concomitant aortic injuries in patients with blunt chest trauma and concomitant cardiac injuries. The role of focused assessment with sonography for trauma (FAST) (or extended-FAST or chest abdominal-FAST in evaluating chest injury) is primarily one of triage; a positive FAST and signs of hemodynamic instability may lead to immediate surgical intervention rather than CT [14,15]. Ultrasound (US) may be able to diagnose certain thoracic and abdominal injuries, but it is an insufficient test to fully exclude injuries to these areas because it has a relatively lower specificity compared with CT [16]. Hemodynamic instability and findings such as abnormal ECG and increased level of high-sensitivity troponin in hemodynamically stable patients should raise the suspicion of cardiac injuries, and these patients should undergo rapid cardiac assessment by echocardiography [7,10]. An initial FAST examination can detect pericardial effusion and wall motion abnormality. Hall et al [11] analyzed the cardiac component of the FAST examination in hypotensive (systolic blood pressure <90 mm Hg) and normotensive trauma patients. | 3082590 |
acrac_3082590_2 | Blunt Chest Trauma Suspected Cardiac Injury | The authors concluded that performing echocardiography in hypotensive blunt trauma patients is effective in evaluating myocardial rupture with limited evaluation of the right ventricle, valvular injuries such as valvular or perivalvular regurgitation, hemopericardium, tamponade, pneumopericardium, and myocardial infarction. The authors have also stressed that a cardiac FAST examination may not be an effective use of resources for normotensive blunt trauma patients. In general, hemodynamically stable patients should be either monitored or evaluated by cardiac imaging if the abnormal ECG findings persist or cardiac troponin levels are rising [7]. Patients with normal ECG and cardiac troponin levels are usually considered low probability for cardiac blunt trauma and therefore can be safely discharged [7,18,19]. CT chest has been accepted as an imaging modality of choice in patients with blunt chest trauma [20-23]. The superior spatial resolution combined with the ability of contrast enhancement to display the anatomic structures and 3-D reconstructions allows for accurate assessment of cardiovascular anatomy and the associated detection of pathology. Ideally, CT chest in patients with suspected cardiac injuries as part of the blunt trauma evaluation should be performed with intravenous (IV) contrast. However, in some instances, CT chest could be performed either without or with and without IV contrast, as described in the CT chest sections below. CT Chest Without IV Contrast In patients with suspected cardiac injury, CT chest studies without IV contrast can easily identify hemothorax or hemopericardium from pleural and pericardial effusion by measuring the attenuation within the pleural or pericardial space. CT chest without IV contrast can also accurately detect sternal fractures by evaluating the sagittal and 3-D reconstructions. | Blunt Chest Trauma Suspected Cardiac Injury. The authors concluded that performing echocardiography in hypotensive blunt trauma patients is effective in evaluating myocardial rupture with limited evaluation of the right ventricle, valvular injuries such as valvular or perivalvular regurgitation, hemopericardium, tamponade, pneumopericardium, and myocardial infarction. The authors have also stressed that a cardiac FAST examination may not be an effective use of resources for normotensive blunt trauma patients. In general, hemodynamically stable patients should be either monitored or evaluated by cardiac imaging if the abnormal ECG findings persist or cardiac troponin levels are rising [7]. Patients with normal ECG and cardiac troponin levels are usually considered low probability for cardiac blunt trauma and therefore can be safely discharged [7,18,19]. CT chest has been accepted as an imaging modality of choice in patients with blunt chest trauma [20-23]. The superior spatial resolution combined with the ability of contrast enhancement to display the anatomic structures and 3-D reconstructions allows for accurate assessment of cardiovascular anatomy and the associated detection of pathology. Ideally, CT chest in patients with suspected cardiac injuries as part of the blunt trauma evaluation should be performed with intravenous (IV) contrast. However, in some instances, CT chest could be performed either without or with and without IV contrast, as described in the CT chest sections below. CT Chest Without IV Contrast In patients with suspected cardiac injury, CT chest studies without IV contrast can easily identify hemothorax or hemopericardium from pleural and pericardial effusion by measuring the attenuation within the pleural or pericardial space. CT chest without IV contrast can also accurately detect sternal fractures by evaluating the sagittal and 3-D reconstructions. | 3082590 |
acrac_3082590_3 | Blunt Chest Trauma Suspected Cardiac Injury | Even though a sternal fracture in the setting of trauma is considered a benign condition, myocardial contusion and myocardial concussion leading to malignant ventricular arrhythmias can be encountered with this finding only if there are ECG changes and cardiac troponin levels are rising. It is difficult to predict which patients with a sternal fracture will develop cardiac complications. In a cohort of 54 patients with a suspected sternal fracture by emergency physicians in a multicenter descriptive retrospective study, only 72% of the patients had ECG performed at baseline, 33% had follow-up ECG, and 30% had troponin I assessment; in this group, 6% of the patients were diagnosed with arrhythmias and myocardial contusion. The authors also showed that only 38 (70%) of the patients with suspected sternal fractures were confirmed by imaging [24]. This study shows the importance of diagnosing sternal fractures in conjunction with ECG monitoring and troponin assessment to evaluate cardiac Blunt Chest Trauma-Suspected Cardiac Injury injury in the setting of blunt trauma. However, it is noteworthy that echocardiography is not recommended in isolated sternal fractures in the presence of a normal ECG and cardiac troponins to evaluate for myocardial contusion [25]. The use of CT chest without IV contrast is of paramount importance in patients with prior chest surgery or retained metal fragments for accurate diagnosis of cardiac trauma and concomitant vascular injuries. CT Chest Without and With IV Contrast CT chest with and without IV contrast is the most effective routine imaging modality for detecting thoracic injuries caused by blunt trauma. It accurately detects hemorrhage within the chest followed by identification of concomitant cardiovascular injuries as a source of bleeding. | Blunt Chest Trauma Suspected Cardiac Injury. Even though a sternal fracture in the setting of trauma is considered a benign condition, myocardial contusion and myocardial concussion leading to malignant ventricular arrhythmias can be encountered with this finding only if there are ECG changes and cardiac troponin levels are rising. It is difficult to predict which patients with a sternal fracture will develop cardiac complications. In a cohort of 54 patients with a suspected sternal fracture by emergency physicians in a multicenter descriptive retrospective study, only 72% of the patients had ECG performed at baseline, 33% had follow-up ECG, and 30% had troponin I assessment; in this group, 6% of the patients were diagnosed with arrhythmias and myocardial contusion. The authors also showed that only 38 (70%) of the patients with suspected sternal fractures were confirmed by imaging [24]. This study shows the importance of diagnosing sternal fractures in conjunction with ECG monitoring and troponin assessment to evaluate cardiac Blunt Chest Trauma-Suspected Cardiac Injury injury in the setting of blunt trauma. However, it is noteworthy that echocardiography is not recommended in isolated sternal fractures in the presence of a normal ECG and cardiac troponins to evaluate for myocardial contusion [25]. The use of CT chest without IV contrast is of paramount importance in patients with prior chest surgery or retained metal fragments for accurate diagnosis of cardiac trauma and concomitant vascular injuries. CT Chest Without and With IV Contrast CT chest with and without IV contrast is the most effective routine imaging modality for detecting thoracic injuries caused by blunt trauma. It accurately detects hemorrhage within the chest followed by identification of concomitant cardiovascular injuries as a source of bleeding. | 3082590 |
acrac_3082590_4 | Blunt Chest Trauma Suspected Cardiac Injury | CT Heart Function and Morphology ECG-gated cardiac CT with IV contrast can be used in the trauma setting to evaluate the cardiac structure and can detect cardiac chamber rupture and pericardial rupture [35]. A case report has described various entities such as rupture of the right ventricle with contained contrast extravasation [36], left atrial appendage tear, rupture of the atria at the junction with pulmonary veins, and inferior vena cava. The existing literature focuses on clinical decision scores along with a chest radiograph, ECG, and troponin assessment [37] as a screening algorithm to triage patients in whom cardiac CT has the potential to guide life-saving interventions. Cardiac CT has been demonstrated to be highly accurate for the detection of cardiac structural abnormalities in the nontrauma setting. A case report described the right ventricular pseudoaneurysm following an MVA diagnosed with cardiac CT and missed with echocardiography [36]. Another case report described contrast extravasation from the apical portion of the right ventricle into the pericardial space compatible with contained ventricular rupture in addition to multiple chest injuries detected at CT [38]. Other case reports have described the ability of contrast-enhanced CT chest to detect enhancement defects in the myocardium suggestive of myocardial infarction in the setting of trauma. These findings triggered further imaging and subsequent intervention [21] to treat coronary artery dissection following blunt trauma [39]. In addition, another case report described a patient with a hemothorax caused by a left atrial appendage rupture, pleuropericardial tear, and cardiac herniation through the pericardium [40]. Moreover, case reports have described the ability of CT chest with IV contrast to detect enhancement defect in the myocardium suggestive of myocardial infarction and ventricular septal defect in the setting of trauma that triggered further imaging and intervention [6,21,41]. | Blunt Chest Trauma Suspected Cardiac Injury. CT Heart Function and Morphology ECG-gated cardiac CT with IV contrast can be used in the trauma setting to evaluate the cardiac structure and can detect cardiac chamber rupture and pericardial rupture [35]. A case report has described various entities such as rupture of the right ventricle with contained contrast extravasation [36], left atrial appendage tear, rupture of the atria at the junction with pulmonary veins, and inferior vena cava. The existing literature focuses on clinical decision scores along with a chest radiograph, ECG, and troponin assessment [37] as a screening algorithm to triage patients in whom cardiac CT has the potential to guide life-saving interventions. Cardiac CT has been demonstrated to be highly accurate for the detection of cardiac structural abnormalities in the nontrauma setting. A case report described the right ventricular pseudoaneurysm following an MVA diagnosed with cardiac CT and missed with echocardiography [36]. Another case report described contrast extravasation from the apical portion of the right ventricle into the pericardial space compatible with contained ventricular rupture in addition to multiple chest injuries detected at CT [38]. Other case reports have described the ability of contrast-enhanced CT chest to detect enhancement defects in the myocardium suggestive of myocardial infarction in the setting of trauma. These findings triggered further imaging and subsequent intervention [21] to treat coronary artery dissection following blunt trauma [39]. In addition, another case report described a patient with a hemothorax caused by a left atrial appendage rupture, pleuropericardial tear, and cardiac herniation through the pericardium [40]. Moreover, case reports have described the ability of CT chest with IV contrast to detect enhancement defect in the myocardium suggestive of myocardial infarction and ventricular septal defect in the setting of trauma that triggered further imaging and intervention [6,21,41]. | 3082590 |
acrac_3082590_5 | Blunt Chest Trauma Suspected Cardiac Injury | CTA Chest Although this document excludes the discussion of vascular injuries, CTA chest without and with IV contrast is useful in a patient with blunt chest trauma and suspected cardiac injury. This is because CT chest can identify the extent of cardiac injury as well as other concomitant injuries in the chest and, most importantly, can be used for surgical planning. Blunt Chest Trauma-Suspected Cardiac Injury CTA Coronary Arteries Coronary CTA evaluates for potential posttraumatic coronary arterial dissection or occlusion resulting in myocardial infarction. There are limited data on the coronary CTA in patients with suspected myocardial infarction in the trauma setting. A case report has described various entities such as intramural hematomas or atypical dissection of the coronary artery [42] and enhancement defects in the myocardium suggestive of myocardial infarction in the setting of trauma. These findings triggered further imaging and subsequent intervention [21] to treat coronary artery dissection following blunt trauma [39]. Several case reports have described the use of coronary angiography as a diagnostic and therapeutic modality [40,43-46] to not only detect coronary artery dissection and thrombosis in patients with ECG abnormalities, or increased serum troponin level, but also treat with angioplasty or coronary artery stent placement. More recently, high-sensitivity cardiac troponins have become the mainstays in an emergency evaluation [7]. FDG-PET/CT Heart Cardiac fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT may be used to assess myocardial function, perfusion, and viability in the trauma setting. [37,47]. There are no data regarding the use of FDG-PET/CT heart in the setting of blunt chest trauma and suspected cardiac injury. MRI Heart Function and Morphology There are no data regarding the use of MRI heart in the setting of blunt chest trauma and suspected cardiac injury. | Blunt Chest Trauma Suspected Cardiac Injury. CTA Chest Although this document excludes the discussion of vascular injuries, CTA chest without and with IV contrast is useful in a patient with blunt chest trauma and suspected cardiac injury. This is because CT chest can identify the extent of cardiac injury as well as other concomitant injuries in the chest and, most importantly, can be used for surgical planning. Blunt Chest Trauma-Suspected Cardiac Injury CTA Coronary Arteries Coronary CTA evaluates for potential posttraumatic coronary arterial dissection or occlusion resulting in myocardial infarction. There are limited data on the coronary CTA in patients with suspected myocardial infarction in the trauma setting. A case report has described various entities such as intramural hematomas or atypical dissection of the coronary artery [42] and enhancement defects in the myocardium suggestive of myocardial infarction in the setting of trauma. These findings triggered further imaging and subsequent intervention [21] to treat coronary artery dissection following blunt trauma [39]. Several case reports have described the use of coronary angiography as a diagnostic and therapeutic modality [40,43-46] to not only detect coronary artery dissection and thrombosis in patients with ECG abnormalities, or increased serum troponin level, but also treat with angioplasty or coronary artery stent placement. More recently, high-sensitivity cardiac troponins have become the mainstays in an emergency evaluation [7]. FDG-PET/CT Heart Cardiac fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT may be used to assess myocardial function, perfusion, and viability in the trauma setting. [37,47]. There are no data regarding the use of FDG-PET/CT heart in the setting of blunt chest trauma and suspected cardiac injury. MRI Heart Function and Morphology There are no data regarding the use of MRI heart in the setting of blunt chest trauma and suspected cardiac injury. | 3082590 |
acrac_3082590_6 | Blunt Chest Trauma Suspected Cardiac Injury | A few case reports describe the use of cardiac MR (CMR) in detecting viable myocardium using late gadolinium enhancement because of myocardial infarction in trauma patients [41,46] and a case report describing a heart herniation [48]. CMR is also useful for detecting cardiac injuries, particularly right ventricular injury and pericardial injury, quantifying valvular regurgitation, and detecting typical or atypical aortic dissection in patients. In many instances, the CMR protocol may be shortened to address the clinical question; however, it is still a longer examination than a CT scan. However, CMR may be helpful in selected patients with suspected cardiac trauma and equivocal echo findings. MRI Heart With Function and Inotropic Stress There is no relevant literature regarding the use of CMR with function and inotropic stress in a hemodynamically stable patient with blunt trauma to evaluate suspected cardiac injuries. MRI Heart With Function and Vasodilator Stress Perfusion There is no relevant literature regarding the use of CMR with function and inotropic stress in a hemodynamically stable patient with blunt trauma to evaluate suspected cardiac injuries. Radiography Chest In any trauma setting, chest radiography is the first imaging modality to identify indirect findings that infer cardiac or pericardial injuries. However, the role of chest radiography in blunt cardiac trauma is often limited in quality because of motion artifacts and overlying devices and garments. Longitudinal prospective studies examining the diagnostic yield of imaging in a blunt cardiac trauma have not been possible because identification of indirect findings that infer cardiac injury are rare and often missed and are mainly discussed in case reports. Chest radiography alone has limited ability to detect traumatic cardiac injuries. | Blunt Chest Trauma Suspected Cardiac Injury. A few case reports describe the use of cardiac MR (CMR) in detecting viable myocardium using late gadolinium enhancement because of myocardial infarction in trauma patients [41,46] and a case report describing a heart herniation [48]. CMR is also useful for detecting cardiac injuries, particularly right ventricular injury and pericardial injury, quantifying valvular regurgitation, and detecting typical or atypical aortic dissection in patients. In many instances, the CMR protocol may be shortened to address the clinical question; however, it is still a longer examination than a CT scan. However, CMR may be helpful in selected patients with suspected cardiac trauma and equivocal echo findings. MRI Heart With Function and Inotropic Stress There is no relevant literature regarding the use of CMR with function and inotropic stress in a hemodynamically stable patient with blunt trauma to evaluate suspected cardiac injuries. MRI Heart With Function and Vasodilator Stress Perfusion There is no relevant literature regarding the use of CMR with function and inotropic stress in a hemodynamically stable patient with blunt trauma to evaluate suspected cardiac injuries. Radiography Chest In any trauma setting, chest radiography is the first imaging modality to identify indirect findings that infer cardiac or pericardial injuries. However, the role of chest radiography in blunt cardiac trauma is often limited in quality because of motion artifacts and overlying devices and garments. Longitudinal prospective studies examining the diagnostic yield of imaging in a blunt cardiac trauma have not been possible because identification of indirect findings that infer cardiac injury are rare and often missed and are mainly discussed in case reports. Chest radiography alone has limited ability to detect traumatic cardiac injuries. | 3082590 |
acrac_3082590_7 | Blunt Chest Trauma Suspected Cardiac Injury | SPECT/CT MPI Rest and Stress Single-photon emission computed tomography (SPECT) may be used to assess myocardial function, perfusion, and viability in the trauma setting. The literature for use of SPECT is contradictory. In a prospective study involving 125 patients that evaluated the use of T1-201 thallous chloride SPECT in blunt chest trauma [49], the authors found that 11 out of 75 patients who screened positive and 3 out of 48 patients who screened negative developed serious arrhythmias such as premature ventricular beats and atrial fibrillation. They concluded that SPECT is useful to evaluate myocardial contusion in patients with blunt chest trauma. A meta-analysis study showed that radionuclide results did not correlate with cardiac complications whereas ECG abnormalities and cardiac troponins did in patients with blunt chest trauma [37]. This could be explained by the fact that SPECT better detects left ventricular abnormalities than right ventricular abnormalities, which are more common in blunt cardiac trauma. SPECT/CT MPI Rest Only There is no relevant literature regarding the use of SPECT/CT MPI rest only to evaluate suspected cardiac injuries. Blunt Chest Trauma-Suspected Cardiac Injury US Echocardiography Transesophageal Transesophageal echocardiography (TEE) can be used in the trauma setting; however, it is often time limited because of the hemodynamic instability of the patients, need for sedation, and concern about esophageal injury. TEE is of value when the TTE findings are equivocal and aortic injury is suspected [50]. In a prospective study of 105 patients with severe blunt chest trauma, 20 patients underwent TEE because of suboptimal TTE findings, 9 of whom were diagnosed with a myocardial contusion and 5 with acute aortic injury [50]. TEE is also useful in evaluating right heart and tricuspid valve [51]. There is no evidence to support the use of TEE in the trauma setting for isolated cardiac injury. | Blunt Chest Trauma Suspected Cardiac Injury. SPECT/CT MPI Rest and Stress Single-photon emission computed tomography (SPECT) may be used to assess myocardial function, perfusion, and viability in the trauma setting. The literature for use of SPECT is contradictory. In a prospective study involving 125 patients that evaluated the use of T1-201 thallous chloride SPECT in blunt chest trauma [49], the authors found that 11 out of 75 patients who screened positive and 3 out of 48 patients who screened negative developed serious arrhythmias such as premature ventricular beats and atrial fibrillation. They concluded that SPECT is useful to evaluate myocardial contusion in patients with blunt chest trauma. A meta-analysis study showed that radionuclide results did not correlate with cardiac complications whereas ECG abnormalities and cardiac troponins did in patients with blunt chest trauma [37]. This could be explained by the fact that SPECT better detects left ventricular abnormalities than right ventricular abnormalities, which are more common in blunt cardiac trauma. SPECT/CT MPI Rest Only There is no relevant literature regarding the use of SPECT/CT MPI rest only to evaluate suspected cardiac injuries. Blunt Chest Trauma-Suspected Cardiac Injury US Echocardiography Transesophageal Transesophageal echocardiography (TEE) can be used in the trauma setting; however, it is often time limited because of the hemodynamic instability of the patients, need for sedation, and concern about esophageal injury. TEE is of value when the TTE findings are equivocal and aortic injury is suspected [50]. In a prospective study of 105 patients with severe blunt chest trauma, 20 patients underwent TEE because of suboptimal TTE findings, 9 of whom were diagnosed with a myocardial contusion and 5 with acute aortic injury [50]. TEE is also useful in evaluating right heart and tricuspid valve [51]. There is no evidence to support the use of TEE in the trauma setting for isolated cardiac injury. | 3082590 |
acrac_3082590_8 | Blunt Chest Trauma Suspected Cardiac Injury | Valvular injuries are also rare but have been reported in the literature. Aortic and mitral valves are the most commonly affected, followed by tricuspid and pulmonic valves, because the mural pressure is higher on the left side of the heart [54]. Valvular injuries can present as perivalvular leak, dehiscence because of papillary muscle or chordae tendineae rupture, tearing of valve leaflets, or papillary muscle contusion leading to necrosis. Aortic and pulmonic valves are vulnerable to injury during early diastole and atrioventricular valves are prone to injury during early systole when the intraventricular pressure is increased [7]. All valvular injuries present with signs and symptoms of regurgitation, therefore, it is prudent to perform echocardiography and assess the severity of regurgitation to guide further management with surgical repair in severe cases. Several case reports describe posttraumatic severe mitral regurgitation requiring surgical repair following MVAs [55-57]. A few case reports have described the use of echocardiography for diagnosing wall motion abnormality in the setting of myocardial infarction and coronary artery dissection after blunt chest trauma, especially when myocardial contusion mimics myocardial infarction with elevated cardiac troponins [42,58]. Prompt identification of wall motion abnormality in coronary artery distribution following blunt chest trauma is important for the identification and treatment of coronary artery dissection. Additionally, when a wall motion abnormality is present in the absence of elevated high-sensitivity cardiac troponins, a diagnosis of myocardial concussion can be made. Myocardial concussion does not cause myocardial anatomic injuries that lead to necrosis and elevated high-sensitivity cardiac troponins but instead stretches the cell membrane, leading to activation of ion channels through mechanical- electrical coupling that trigger ventricular arrhythmias [59]. | Blunt Chest Trauma Suspected Cardiac Injury. Valvular injuries are also rare but have been reported in the literature. Aortic and mitral valves are the most commonly affected, followed by tricuspid and pulmonic valves, because the mural pressure is higher on the left side of the heart [54]. Valvular injuries can present as perivalvular leak, dehiscence because of papillary muscle or chordae tendineae rupture, tearing of valve leaflets, or papillary muscle contusion leading to necrosis. Aortic and pulmonic valves are vulnerable to injury during early diastole and atrioventricular valves are prone to injury during early systole when the intraventricular pressure is increased [7]. All valvular injuries present with signs and symptoms of regurgitation, therefore, it is prudent to perform echocardiography and assess the severity of regurgitation to guide further management with surgical repair in severe cases. Several case reports describe posttraumatic severe mitral regurgitation requiring surgical repair following MVAs [55-57]. A few case reports have described the use of echocardiography for diagnosing wall motion abnormality in the setting of myocardial infarction and coronary artery dissection after blunt chest trauma, especially when myocardial contusion mimics myocardial infarction with elevated cardiac troponins [42,58]. Prompt identification of wall motion abnormality in coronary artery distribution following blunt chest trauma is important for the identification and treatment of coronary artery dissection. Additionally, when a wall motion abnormality is present in the absence of elevated high-sensitivity cardiac troponins, a diagnosis of myocardial concussion can be made. Myocardial concussion does not cause myocardial anatomic injuries that lead to necrosis and elevated high-sensitivity cardiac troponins but instead stretches the cell membrane, leading to activation of ion channels through mechanical- electrical coupling that trigger ventricular arrhythmias [59]. | 3082590 |
acrac_3082590_9 | Blunt Chest Trauma Suspected Cardiac Injury | In summary, TTE is the first-line imaging modality used in evaluation of blunt cardiac trauma in patients with abnormal ECG and elevated cardiac troponins. US Echocardiography Transthoracic Stress There is no relevant literature regarding the use of TTE stress in suspected myocardial infarction in the trauma setting. Variant 2: Suspected cardiac injury following blunt trauma, hemodynamically unstable patient. Hemodynamically unstable patients are defined as persistent hypotension (systolic blood pressure <90 mm Hg or mean blood pressure <65 mm Hg) despite fluid resuscitation [17]. Hemodynamically unstable patients with ECG changes and elevated cardiac troponins worrisome for cardiac trauma are usually managed with advanced cardiac life support followed by echocardiography evaluation [7]. On the contrary, hemodynamically unstable patients with normal ECG and cardiac troponins are usually admitted for monitoring and echocardiography is only indicated for unstable patients with rising troponin levels [7]. Blunt Chest Trauma-Suspected Cardiac Injury CT Chest CT chest plays a complementary role in defining the extent of blunt cardiac trauma and is typically reserved for surgical planning in patients with ongoing symptoms and unclear clinical etiology [7]. For this purpose, CT in a hemodynamically unstable patient with blunt trauma is useful despite the lack of relevant literature to support this statement. CT Heart Function and Morphology CT heart in a hemodynamically unstable patient with blunt trauma and possible cardiac injury is useful in clinically indicated scenarios despite the lack of direct evidence. CTA Chest The use of CTA chest is helpful in a hemodynamically unstable patient with blunt trauma and possible cardiac injury if clinically indicated to define the extent of blunt chest trauma and identify concomitant thoracic injuries; it is also helpful for surgical planning. | Blunt Chest Trauma Suspected Cardiac Injury. In summary, TTE is the first-line imaging modality used in evaluation of blunt cardiac trauma in patients with abnormal ECG and elevated cardiac troponins. US Echocardiography Transthoracic Stress There is no relevant literature regarding the use of TTE stress in suspected myocardial infarction in the trauma setting. Variant 2: Suspected cardiac injury following blunt trauma, hemodynamically unstable patient. Hemodynamically unstable patients are defined as persistent hypotension (systolic blood pressure <90 mm Hg or mean blood pressure <65 mm Hg) despite fluid resuscitation [17]. Hemodynamically unstable patients with ECG changes and elevated cardiac troponins worrisome for cardiac trauma are usually managed with advanced cardiac life support followed by echocardiography evaluation [7]. On the contrary, hemodynamically unstable patients with normal ECG and cardiac troponins are usually admitted for monitoring and echocardiography is only indicated for unstable patients with rising troponin levels [7]. Blunt Chest Trauma-Suspected Cardiac Injury CT Chest CT chest plays a complementary role in defining the extent of blunt cardiac trauma and is typically reserved for surgical planning in patients with ongoing symptoms and unclear clinical etiology [7]. For this purpose, CT in a hemodynamically unstable patient with blunt trauma is useful despite the lack of relevant literature to support this statement. CT Heart Function and Morphology CT heart in a hemodynamically unstable patient with blunt trauma and possible cardiac injury is useful in clinically indicated scenarios despite the lack of direct evidence. CTA Chest The use of CTA chest is helpful in a hemodynamically unstable patient with blunt trauma and possible cardiac injury if clinically indicated to define the extent of blunt chest trauma and identify concomitant thoracic injuries; it is also helpful for surgical planning. | 3082590 |
acrac_3082590_10 | Blunt Chest Trauma Suspected Cardiac Injury | However, there is no relevant literature to support the use of CTA chest in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. CTA Coronary Arteries The lack of evidence does not support the use of CTA coronary in a hemodynamically unstable patient with blunt trauma and possible cardiac injury, but it could be done if clinically indicated. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. MRI Heart Function and Morphology There is no relevant literature to support the use of CMR function and morphology in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. MRI Heart With Function and Inotropic Stress There is no relevant literature regarding the use of CMR stress in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. MRI Heart With Function and Vasodilator Stress Perfusion There is no relevant literature regarding the use of CMR stress in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. Radiography Chest Bedside anteroposterior (AP) chest radiographs are commonly used as a first-line imaging modality in the evaluation of blunt thoracic trauma at most level I trauma centers in the United States, especially in hemodynamically unstable patients [26,60]. AP chest radiographs have limited ability to identify the direct findings of blunt cardiac injuries such as cardiac rupture, coronary artery dissection, pericardial tear, and valvular injuries. However, radiographs have the potential to identify indirect findings that infer cardiac or pericardial injuries. These indirect findings include hemothorax, widened mediastinum, enlarged cardiomediastinal silhouette, abnormal cardiac silhouette contour, changing cardiac position after tube thoracotomy, pneumopericardium, and displaced rib fractures, especially between the third and ninth ribs. | Blunt Chest Trauma Suspected Cardiac Injury. However, there is no relevant literature to support the use of CTA chest in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. CTA Coronary Arteries The lack of evidence does not support the use of CTA coronary in a hemodynamically unstable patient with blunt trauma and possible cardiac injury, but it could be done if clinically indicated. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. MRI Heart Function and Morphology There is no relevant literature to support the use of CMR function and morphology in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. MRI Heart With Function and Inotropic Stress There is no relevant literature regarding the use of CMR stress in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. MRI Heart With Function and Vasodilator Stress Perfusion There is no relevant literature regarding the use of CMR stress in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. Radiography Chest Bedside anteroposterior (AP) chest radiographs are commonly used as a first-line imaging modality in the evaluation of blunt thoracic trauma at most level I trauma centers in the United States, especially in hemodynamically unstable patients [26,60]. AP chest radiographs have limited ability to identify the direct findings of blunt cardiac injuries such as cardiac rupture, coronary artery dissection, pericardial tear, and valvular injuries. However, radiographs have the potential to identify indirect findings that infer cardiac or pericardial injuries. These indirect findings include hemothorax, widened mediastinum, enlarged cardiomediastinal silhouette, abnormal cardiac silhouette contour, changing cardiac position after tube thoracotomy, pneumopericardium, and displaced rib fractures, especially between the third and ninth ribs. | 3082590 |
acrac_3082590_11 | Blunt Chest Trauma Suspected Cardiac Injury | These findings coupled with the appropriate clinical presentation should trigger a further evaluation of potential life-threatening cardiac and pericardial injuries [61-63]. Attention should be paid in patients with cardiac implantable electronic devices for possible device header fracture, lead fracture, or lead migration [64]. A case report of chest trauma that resulted in device malfunction showed an abnormal angulation between the device header and the body of the generator on a lateral chest radiograph [65]. Although an AP chest radiograph is the first-line imaging in trauma patients, it is often limited in quality because of motion artifacts and overlying devices and garments. The evaluation of the mediastinum is also limited with only an AP projection image. Several studies have evaluated the diagnostic yield of the chest radiograph in the assessment of blunt thoracic injuries and have shown the value of using chest radiographs, especially when coupled with abdominal CT, chest CT, or a clinical decision score [23,66-73]. AP chest radiograph has a lower diagnostic yield for occult blunt traumatic injuries than chest CT, missing 80% of cases of hemothorax and 50% of vertebral and rib fractures compared with CT [68,69,72,73]. Hemothorax or hemopericardium can result from cardiac rupture and pericardial tamponade; sternal fracture can result in cardiac contusion or even rupture. Overall, chest radiography alone has limited ability to detect traumatic cardiac injuries. Blunt Chest Trauma-Suspected Cardiac Injury SPECT/CT MPI Rest and Stress There is no relevant literature regarding the use of Tc-99m SPECT/CT MPI rest and stress in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. SPECT/CT MPI Rest Only There is no relevant literature regarding the use of Tc-99m SPECT/CT MPI rest only in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. | Blunt Chest Trauma Suspected Cardiac Injury. These findings coupled with the appropriate clinical presentation should trigger a further evaluation of potential life-threatening cardiac and pericardial injuries [61-63]. Attention should be paid in patients with cardiac implantable electronic devices for possible device header fracture, lead fracture, or lead migration [64]. A case report of chest trauma that resulted in device malfunction showed an abnormal angulation between the device header and the body of the generator on a lateral chest radiograph [65]. Although an AP chest radiograph is the first-line imaging in trauma patients, it is often limited in quality because of motion artifacts and overlying devices and garments. The evaluation of the mediastinum is also limited with only an AP projection image. Several studies have evaluated the diagnostic yield of the chest radiograph in the assessment of blunt thoracic injuries and have shown the value of using chest radiographs, especially when coupled with abdominal CT, chest CT, or a clinical decision score [23,66-73]. AP chest radiograph has a lower diagnostic yield for occult blunt traumatic injuries than chest CT, missing 80% of cases of hemothorax and 50% of vertebral and rib fractures compared with CT [68,69,72,73]. Hemothorax or hemopericardium can result from cardiac rupture and pericardial tamponade; sternal fracture can result in cardiac contusion or even rupture. Overall, chest radiography alone has limited ability to detect traumatic cardiac injuries. Blunt Chest Trauma-Suspected Cardiac Injury SPECT/CT MPI Rest and Stress There is no relevant literature regarding the use of Tc-99m SPECT/CT MPI rest and stress in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. SPECT/CT MPI Rest Only There is no relevant literature regarding the use of Tc-99m SPECT/CT MPI rest only in a hemodynamically unstable patient with blunt trauma and possible cardiac injury. | 3082590 |
acrac_3102409_0 | Altered Mental Status Coma Delirium and Psychosis | Introduction/Background Altered mental status (AMS) and coma are terms used to describe disorders of arousal and content of consciousness. AMS may account for up to 4% to 10% of chief complaints in the emergency department (ED) setting and is a common accompanying symptom for other presentations [1,2]. AMS is not a diagnosis but rather a term for symptoms of acute or chronic disordered mentation [1], including confusion, disorientation, lethargy, drowsiness, somnolence, unresponsiveness, agitation, altered behavior, inattention, hallucinations, delusions, and psychosis [3,4]. Some of the most common disorders associated with AMS are underlying medical conditions, substance use, and mental disorders [5]. Validated assessment scales, such as the Richmond Agitation Sedation Scale and Glasgow Coma Scale, may be employed to objectively quantify the severity of symptoms [3,4]. The cause of AMS in patients across all age groups remains undiagnosed in slightly >5% of cases. Overall mortality in patients with AMS is approximately 8.1% and is significantly higher in elderly patients [4]. Two studies found that older patients presenting to the ED with the nonspecific chief complaint of AMS are likely to have delirium [6]. Delirium is a defined and diagnosable medical condition under Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, which includes inattention as a cardinal feature, may fluctuate over the course of day with lucid intervals, and may present with subtle disturbances in consciousness compared with other forms of acute AMS, making detection more difficult and thus easy to miss [3,6]. Delirium is considered a medical emergency. Early detection and accurate diagnosis are extremely important because mortality in patients may be twice as high if the diagnosis of delirium is missed [7]. | Altered Mental Status Coma Delirium and Psychosis. Introduction/Background Altered mental status (AMS) and coma are terms used to describe disorders of arousal and content of consciousness. AMS may account for up to 4% to 10% of chief complaints in the emergency department (ED) setting and is a common accompanying symptom for other presentations [1,2]. AMS is not a diagnosis but rather a term for symptoms of acute or chronic disordered mentation [1], including confusion, disorientation, lethargy, drowsiness, somnolence, unresponsiveness, agitation, altered behavior, inattention, hallucinations, delusions, and psychosis [3,4]. Some of the most common disorders associated with AMS are underlying medical conditions, substance use, and mental disorders [5]. Validated assessment scales, such as the Richmond Agitation Sedation Scale and Glasgow Coma Scale, may be employed to objectively quantify the severity of symptoms [3,4]. The cause of AMS in patients across all age groups remains undiagnosed in slightly >5% of cases. Overall mortality in patients with AMS is approximately 8.1% and is significantly higher in elderly patients [4]. Two studies found that older patients presenting to the ED with the nonspecific chief complaint of AMS are likely to have delirium [6]. Delirium is a defined and diagnosable medical condition under Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, which includes inattention as a cardinal feature, may fluctuate over the course of day with lucid intervals, and may present with subtle disturbances in consciousness compared with other forms of acute AMS, making detection more difficult and thus easy to miss [3,6]. Delirium is considered a medical emergency. Early detection and accurate diagnosis are extremely important because mortality in patients may be twice as high if the diagnosis of delirium is missed [7]. | 3102409 |
acrac_3102409_1 | Altered Mental Status Coma Delirium and Psychosis | Up to 10% to 31% of patients may have delirium at admission, and it may develop in up to 56% of admitted patients [8], particularly following surgery or in the intensive care unit [8]. Delirium is commonly precipitated by 1 or more underlying cause, including another medical condition, intoxication, or withdrawal [9]. Management is based on treatment of the underlying cause, control of symptoms with nonpharmacological approaches, medication when deemed appropriate, and effective aftercare planning [3,6,10]. The economic impact of delirium in the United States is profound, with total costs estimated at $38 to $152 billion each year [11]. New onset psychosis is often listed as a separate subgroup under the AMS category. Delusions and hallucinations are 2 cardinal features of psychotic symptomatology. Additional symptoms may include disorganized speech or thought, disorganized or abnormal motor behavior including catatonia or agitation, and negative symptoms such as diminished expression of emotions [9]. In contrast with other presentations of AMS, awareness and level of consciousness in patients with psychosis are frequently intact [12]. If the psychotic symptoms are related to an underlying psychiatric disorder, such as schizophrenia, bipolar disorder, schizoaffective disorder, or depression with psychotic features, it is termed primary psychosis. Secondary causes of psychosis are thought to be directly related to drug/alcohol use, withdrawal, or an underlying medical cause [1,2] and are not better explained by delirium [9]. Medical conditions that may present with psychotic symptoms include endocrine disorders, autoimmune diseases, neoplasms and paraneoplastic processes, neurologic disorders, infections, genetic or aStanford University School of Medicine, Stanford, California. bPanel Chair, Uniformed Services University, Bethesda, Maryland. cPanel Vice-Chair, Columbia University Medical Center, New York, New York. | Altered Mental Status Coma Delirium and Psychosis. Up to 10% to 31% of patients may have delirium at admission, and it may develop in up to 56% of admitted patients [8], particularly following surgery or in the intensive care unit [8]. Delirium is commonly precipitated by 1 or more underlying cause, including another medical condition, intoxication, or withdrawal [9]. Management is based on treatment of the underlying cause, control of symptoms with nonpharmacological approaches, medication when deemed appropriate, and effective aftercare planning [3,6,10]. The economic impact of delirium in the United States is profound, with total costs estimated at $38 to $152 billion each year [11]. New onset psychosis is often listed as a separate subgroup under the AMS category. Delusions and hallucinations are 2 cardinal features of psychotic symptomatology. Additional symptoms may include disorganized speech or thought, disorganized or abnormal motor behavior including catatonia or agitation, and negative symptoms such as diminished expression of emotions [9]. In contrast with other presentations of AMS, awareness and level of consciousness in patients with psychosis are frequently intact [12]. If the psychotic symptoms are related to an underlying psychiatric disorder, such as schizophrenia, bipolar disorder, schizoaffective disorder, or depression with psychotic features, it is termed primary psychosis. Secondary causes of psychosis are thought to be directly related to drug/alcohol use, withdrawal, or an underlying medical cause [1,2] and are not better explained by delirium [9]. Medical conditions that may present with psychotic symptoms include endocrine disorders, autoimmune diseases, neoplasms and paraneoplastic processes, neurologic disorders, infections, genetic or aStanford University School of Medicine, Stanford, California. bPanel Chair, Uniformed Services University, Bethesda, Maryland. cPanel Vice-Chair, Columbia University Medical Center, New York, New York. | 3102409 |
acrac_3102409_2 | Altered Mental Status Coma Delirium and Psychosis | dClinica Family Health, Lafayette, Colorado; American Academy of Family Physicians. eUniversity of Virginia Health System, Charlottesville, Virginia. fUniversity of Michigan, Ann Arbor, Michigan; Commission on Nuclear Medicine and Molecular Imaging. gMontefiore Medical Center, Bronx, New York. hSan Antonio Military Medical Center, San Antonio, Texas; American Academy of Neurology. iUniversity of Washington, Seattle, Washington and University of British Columbia, Vancouver, British Columbia, Canada. jInova Fairfax Hospital, Falls Church, Virginia; American Psychiatric Association. kWeill Cornell Medical College, New York, New York. lThe University of Tennessee Health Science Center, Memphis, Tennessee; Society of General Internal Medicine. mUniversity of Chicago, Chicago, Illinois. nBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. oCedars-Sinai, Los Angeles, California; American Geriatrics Society. pNaval Medical Center Portsmouth, Portsmouth, Virginia. qUniversity of Colorado School of Medicine, Aurora, Colorado. rUniversity of Cincinnati Medical Center, Cincinnati, Ohio. sSpecialty Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Altered Mental Status, Coma, Delirium, and Psychosis metabolic disorders, nutritional deficiencies, and drug-related intoxication, withdrawal, side effects, and toxicity. For secondary causes of psychosis, treatment is aimed at the underlying medical cause and control of the psychotic symptoms [12]. | Altered Mental Status Coma Delirium and Psychosis. dClinica Family Health, Lafayette, Colorado; American Academy of Family Physicians. eUniversity of Virginia Health System, Charlottesville, Virginia. fUniversity of Michigan, Ann Arbor, Michigan; Commission on Nuclear Medicine and Molecular Imaging. gMontefiore Medical Center, Bronx, New York. hSan Antonio Military Medical Center, San Antonio, Texas; American Academy of Neurology. iUniversity of Washington, Seattle, Washington and University of British Columbia, Vancouver, British Columbia, Canada. jInova Fairfax Hospital, Falls Church, Virginia; American Psychiatric Association. kWeill Cornell Medical College, New York, New York. lThe University of Tennessee Health Science Center, Memphis, Tennessee; Society of General Internal Medicine. mUniversity of Chicago, Chicago, Illinois. nBrigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER. oCedars-Sinai, Los Angeles, California; American Geriatrics Society. pNaval Medical Center Portsmouth, Portsmouth, Virginia. qUniversity of Colorado School of Medicine, Aurora, Colorado. rUniversity of Cincinnati Medical Center, Cincinnati, Ohio. sSpecialty Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Altered Mental Status, Coma, Delirium, and Psychosis metabolic disorders, nutritional deficiencies, and drug-related intoxication, withdrawal, side effects, and toxicity. For secondary causes of psychosis, treatment is aimed at the underlying medical cause and control of the psychotic symptoms [12]. | 3102409 |
acrac_3102409_3 | Altered Mental Status Coma Delirium and Psychosis | Treatment of primary causes of psychosis involves pharmacologic management with antipsychotic medications, psychological therapy, and psychosocial interventions [13]. This article focuses on the appropriateness of neuroimaging in adult patients presenting with AMS changes including new onset delirium or new onset psychosis. In these cases, imaging is often expedited for initial stabilization and to exclude an intracranial process requiring intervention. The diagnosis of delirium in the ED setting can be missed by inadequate screening [3,14], although ED physicians are moderately accurate at establishing the correct clinical diagnosis for the cause of AMS within the first 20 minutes of the patient encounter [15]. The complete evaluation for underlying causes, such as chest radiography to assess for pneumonia, electrocardiogram to assess for myocardial ischemia, electroencephalography for suspected convulsive or nonconvulsive seizure, and lumbar puncture to assess for central nervous system infection, is beyond the scope of this article [3,7]. OR Discussion of Procedures by Variant Variant 1: Adult. Altered mental status. Suspected intracranial pathology or focal neurologic deficit. Initial imaging. Identifying patients with AMS or delirium secondary to acute intracranial pathology is extremely important to guide management and ensure early appropriate triage. This variant encompasses a select group of patients presenting with acute mental status changes at a relatively higher risk of acute intracranial pathology. The yield of neuroimaging studies in patients with AMS is low. A recent meta-analysis of 25 studies including a total of 79,201 patients with atraumatic AMS showed that 94% had undergone a head CT examination, with relevant abnormal findings in only 11% [24]. In a large study of more than 708,145 adult ED encounters, 58,783 CT head Altered Mental Status, Coma, Delirium, and Psychosis | Altered Mental Status Coma Delirium and Psychosis. Treatment of primary causes of psychosis involves pharmacologic management with antipsychotic medications, psychological therapy, and psychosocial interventions [13]. This article focuses on the appropriateness of neuroimaging in adult patients presenting with AMS changes including new onset delirium or new onset psychosis. In these cases, imaging is often expedited for initial stabilization and to exclude an intracranial process requiring intervention. The diagnosis of delirium in the ED setting can be missed by inadequate screening [3,14], although ED physicians are moderately accurate at establishing the correct clinical diagnosis for the cause of AMS within the first 20 minutes of the patient encounter [15]. The complete evaluation for underlying causes, such as chest radiography to assess for pneumonia, electrocardiogram to assess for myocardial ischemia, electroencephalography for suspected convulsive or nonconvulsive seizure, and lumbar puncture to assess for central nervous system infection, is beyond the scope of this article [3,7]. OR Discussion of Procedures by Variant Variant 1: Adult. Altered mental status. Suspected intracranial pathology or focal neurologic deficit. Initial imaging. Identifying patients with AMS or delirium secondary to acute intracranial pathology is extremely important to guide management and ensure early appropriate triage. This variant encompasses a select group of patients presenting with acute mental status changes at a relatively higher risk of acute intracranial pathology. The yield of neuroimaging studies in patients with AMS is low. A recent meta-analysis of 25 studies including a total of 79,201 patients with atraumatic AMS showed that 94% had undergone a head CT examination, with relevant abnormal findings in only 11% [24]. In a large study of more than 708,145 adult ED encounters, 58,783 CT head Altered Mental Status, Coma, Delirium, and Psychosis | 3102409 |
acrac_3102409_4 | Altered Mental Status Coma Delirium and Psychosis | examinations were ordered, with an overall critical result yield of 8.0%. CT head examinations performed for a complaint of AMS had a yield of 9.8% [25]. A study of 285 febrile elderly patients with AMS showed abnormal brain imaging in 16.5%. The most common neurological diagnoses in patients admitted to the ED were intracranial hemorrhage (ICH) and ischemic stroke [26]. Lower Glasgow Coma Scale, the presence of lateralizing sign, higher systolic blood pressure, and lower body temperature were significantly associated with abnormal brain imaging in febrile elderly patients with AMS [26]. The prevalence of delirium in the ED ranges from 7% to 35%. Four factors with strong associations with ED delirium are nursing home residence, cognitive impairment, hearing impairment, and a history of stroke [27]. There are a wide range of precipitating factors leading to delirium onset that make evaluation challenging, some of which are life threatening. These may be related to systemic disease, such as sepsis or infection, hypoxia, metabolic derangements, hypoglycemia, hyperglycemia, hyponatremia, hypothermia, acute myocardial infarction, neurologic disease including stroke, ICH, Wernicke encephalopathy (thiamine deficiency), central nervous system infection, seizure, surgery, trauma, drugs such as anticholinergic drugs, sedatives, narcotics, drug or alcohol withdrawal, polypharmacy, environmental factors from restraints, stress or pain, and sleep deprivation. There is relatively little evidence in the literature regarding appropriate use of neuroimaging with new onset delirium. CT Head With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. In the setting of AMS, contrast- enhanced CT examinations can be considered if intracranial infection, tumor, or inflammatory pathologies are suspected. | Altered Mental Status Coma Delirium and Psychosis. examinations were ordered, with an overall critical result yield of 8.0%. CT head examinations performed for a complaint of AMS had a yield of 9.8% [25]. A study of 285 febrile elderly patients with AMS showed abnormal brain imaging in 16.5%. The most common neurological diagnoses in patients admitted to the ED were intracranial hemorrhage (ICH) and ischemic stroke [26]. Lower Glasgow Coma Scale, the presence of lateralizing sign, higher systolic blood pressure, and lower body temperature were significantly associated with abnormal brain imaging in febrile elderly patients with AMS [26]. The prevalence of delirium in the ED ranges from 7% to 35%. Four factors with strong associations with ED delirium are nursing home residence, cognitive impairment, hearing impairment, and a history of stroke [27]. There are a wide range of precipitating factors leading to delirium onset that make evaluation challenging, some of which are life threatening. These may be related to systemic disease, such as sepsis or infection, hypoxia, metabolic derangements, hypoglycemia, hyperglycemia, hyponatremia, hypothermia, acute myocardial infarction, neurologic disease including stroke, ICH, Wernicke encephalopathy (thiamine deficiency), central nervous system infection, seizure, surgery, trauma, drugs such as anticholinergic drugs, sedatives, narcotics, drug or alcohol withdrawal, polypharmacy, environmental factors from restraints, stress or pain, and sleep deprivation. There is relatively little evidence in the literature regarding appropriate use of neuroimaging with new onset delirium. CT Head With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. In the setting of AMS, contrast- enhanced CT examinations can be considered if intracranial infection, tumor, or inflammatory pathologies are suspected. | 3102409 |
acrac_3102409_5 | Altered Mental Status Coma Delirium and Psychosis | However, the use of contrast-enhanced head CTs as a first-line test in the acute setting does not add significant value over noncontrast head CT examinations [28]. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without intravenous (IV) contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. The reported detection of treatment-altering findings on head CT is very low in elderly patients with new onset delirium unless 1 of the following risk factors is present: focal neurologic deficit, history of recent falls or head injury, anticoagulation therapy, signs of elevated intracranial pressure, or significant deterioration of consciousness [8,38-40]. Acute pathology that resulted in a change of management was detected in a small proportion of patients on head CT, including ischemic and hemorrhagic stroke, subdural hematoma, subarachnoid hemorrhage (SAH), encephalitis or meningitis, and cerebral tumors. Therefore, the low diagnostic yield of CT in this setting must be weighed against the risk of possible, preventable morbidity [8,10], acknowledging that patients may not have clinical signs on examination that predict a focal pathology [34]. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. Altered Mental Status, Coma, Delirium, and Psychosis MRI Head Without and With IV Contrast MRI examinations without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected. | Altered Mental Status Coma Delirium and Psychosis. However, the use of contrast-enhanced head CTs as a first-line test in the acute setting does not add significant value over noncontrast head CT examinations [28]. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without intravenous (IV) contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. The reported detection of treatment-altering findings on head CT is very low in elderly patients with new onset delirium unless 1 of the following risk factors is present: focal neurologic deficit, history of recent falls or head injury, anticoagulation therapy, signs of elevated intracranial pressure, or significant deterioration of consciousness [8,38-40]. Acute pathology that resulted in a change of management was detected in a small proportion of patients on head CT, including ischemic and hemorrhagic stroke, subdural hematoma, subarachnoid hemorrhage (SAH), encephalitis or meningitis, and cerebral tumors. Therefore, the low diagnostic yield of CT in this setting must be weighed against the risk of possible, preventable morbidity [8,10], acknowledging that patients may not have clinical signs on examination that predict a focal pathology [34]. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. Altered Mental Status, Coma, Delirium, and Psychosis MRI Head Without and With IV Contrast MRI examinations without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected. | 3102409 |
acrac_3102409_6 | Altered Mental Status Coma Delirium and Psychosis | In patients with delirium, brain MRI without and with IV contrast may be helpful for the definitive characterization of a focal lesion identified on initial noncontrast CT or in patients with known cancer history [10]. In a simulated decision-making study using a prospective intensive care unit cohort, a panel of neurocritical experts first reviewed clinical information (without MRI) from 75 patients with acute disorder of consciousness patients and made decisions about diagnosis, prognosis, and treatment. Review of head MRI examinations led to changes in clinical management of 76% of patients including revised diagnoses in 20%, revised levels of care in 21%, improved diagnostic confidence in 43%, and improved prognostications in 33% [37]. However, decisions were revised more often with stroke (which commonly presents with focal neurological deficits) than with other brain injuries. Many of the abnormal findings in the literature for this topic included small ischemic infarcts [29,35,36]. Notably, a retrospective study found that 70% of patients who had a missed ischemic stroke diagnosis presented with AMS [33]. MRI of the brain is complementary to an abnormal head CT for the evaluation of suspected intracranial mass lesions, intracranial infection, nonspecific regions of edema, ischemia, and cases of ICH when an underlying lesion is suspected [38]. MRI may also be considered as a first-line test in certain situations, such as a clinically stable patient with known malignancy, HIV, or endocarditis. Noncontrast MRI examinations of the brain are usually sufficient in the assessment of intracranial complications related to hypertensive emergency, including posterior reversible encephalopathy syndrome. In patients with new onset delirium, the reported yield of brain MRI is very low in the absence of a focal neurologic deficit or history of recent falls. | Altered Mental Status Coma Delirium and Psychosis. In patients with delirium, brain MRI without and with IV contrast may be helpful for the definitive characterization of a focal lesion identified on initial noncontrast CT or in patients with known cancer history [10]. In a simulated decision-making study using a prospective intensive care unit cohort, a panel of neurocritical experts first reviewed clinical information (without MRI) from 75 patients with acute disorder of consciousness patients and made decisions about diagnosis, prognosis, and treatment. Review of head MRI examinations led to changes in clinical management of 76% of patients including revised diagnoses in 20%, revised levels of care in 21%, improved diagnostic confidence in 43%, and improved prognostications in 33% [37]. However, decisions were revised more often with stroke (which commonly presents with focal neurological deficits) than with other brain injuries. Many of the abnormal findings in the literature for this topic included small ischemic infarcts [29,35,36]. Notably, a retrospective study found that 70% of patients who had a missed ischemic stroke diagnosis presented with AMS [33]. MRI of the brain is complementary to an abnormal head CT for the evaluation of suspected intracranial mass lesions, intracranial infection, nonspecific regions of edema, ischemia, and cases of ICH when an underlying lesion is suspected [38]. MRI may also be considered as a first-line test in certain situations, such as a clinically stable patient with known malignancy, HIV, or endocarditis. Noncontrast MRI examinations of the brain are usually sufficient in the assessment of intracranial complications related to hypertensive emergency, including posterior reversible encephalopathy syndrome. In patients with new onset delirium, the reported yield of brain MRI is very low in the absence of a focal neurologic deficit or history of recent falls. | 3102409 |
acrac_3102409_7 | Altered Mental Status Coma Delirium and Psychosis | In a small proportion of patients, brain MRI did reveal acute pathology possibly accounting for delirium, including ischemic and hemorrhagic stroke, subdural hematoma, SAH, septic emboli, encephalitis, meningitis, cerebral metastases, primary brain tumor, pineal tumor, and a large meningioma [34]. MRI may be helpful for further evaluation of an abnormality detected on noncontrast CT in the workup of new onset delirium, such as space-occupying lesions or infection. CT Head With IV Contrast Contrast-enhanced CT examinations may be considered if clinical concern exists for progression of intracranial infection, such as abscesses or empyema, tumor, or inflammatory conditions. Advantages of CT are fast examination times and less susceptibility to motion artifact compared with MRI. Disadvantages of CT include less sensitivity in detection of acute ischemia and enhancement compared with MRI [30]. Overall, MRI is considered superior in this clinical scenario. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. CT Head Without IV Contrast CT is the first-line imaging test of choice for evaluating suspected progressive ICH, mass effect, or hydrocephalus in the emergent setting. Noncontrast head CT examinations are able to depict possible complications of a wide variety of intracranial pathology, including progressive mass effect, increasing edema, hydrocephalus, new or enlarging ICH, and progressive ischemia. However, the literature search did not identify any studies regarding the 6 Altered Mental Status, Coma, Delirium, and Psychosis use of CT in the evaluation of acute or worsening mental status changes in a patient with known intracranial pathology. | Altered Mental Status Coma Delirium and Psychosis. In a small proportion of patients, brain MRI did reveal acute pathology possibly accounting for delirium, including ischemic and hemorrhagic stroke, subdural hematoma, SAH, septic emboli, encephalitis, meningitis, cerebral metastases, primary brain tumor, pineal tumor, and a large meningioma [34]. MRI may be helpful for further evaluation of an abnormality detected on noncontrast CT in the workup of new onset delirium, such as space-occupying lesions or infection. CT Head With IV Contrast Contrast-enhanced CT examinations may be considered if clinical concern exists for progression of intracranial infection, such as abscesses or empyema, tumor, or inflammatory conditions. Advantages of CT are fast examination times and less susceptibility to motion artifact compared with MRI. Disadvantages of CT include less sensitivity in detection of acute ischemia and enhancement compared with MRI [30]. Overall, MRI is considered superior in this clinical scenario. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. CT Head Without IV Contrast CT is the first-line imaging test of choice for evaluating suspected progressive ICH, mass effect, or hydrocephalus in the emergent setting. Noncontrast head CT examinations are able to depict possible complications of a wide variety of intracranial pathology, including progressive mass effect, increasing edema, hydrocephalus, new or enlarging ICH, and progressive ischemia. However, the literature search did not identify any studies regarding the 6 Altered Mental Status, Coma, Delirium, and Psychosis use of CT in the evaluation of acute or worsening mental status changes in a patient with known intracranial pathology. | 3102409 |
acrac_3102409_8 | Altered Mental Status Coma Delirium and Psychosis | MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. MRI Head Without and With IV Contrast MRI is the imaging test of choice in the evaluation of suspected progressive inflammatory conditions, such as multiple sclerosis or neuropsychiatric systemic lupus erythematosus. In the assessment of known ICH, MRI is usually not required unless there is suspicion for an underlying mass or lesion or if axonal shear injury is suspected. MRI without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected. MRI Head Without IV Contrast MRI is complementary to CT in the evaluation of suspected progression of intracranial mass lesions, infection, and ischemia and may be performed as a first-line test instead of CT. However, the literature search did not identify any studies regarding the use of MRI in the evaluation of acute or worsening mental status changes in a patient with known intracranial pathology. Advantages of MRI include higher sensitivity for the detection of ischemia, encephalitis, subtle cases of SAH, and enhancement of pathology compared with CT and the potential to use advanced imaging applications that may provide critical information, such as diffusion-weighted imaging, MR perfusion, susceptibility-weighted sequences, and MR spectroscopy. Disadvantages of MRI include longer examination time, susceptibility to motion artifacts, and implanted devices that are not MRI safe [2]. Variant 3: Adult. Altered mental status. Suspected medical illness or toxic-metabolic cause. Initial imaging. Acute mental status changes may be triggered by a wide range of medical conditions, including drugs and intoxication, system or organ dysfunction, and metabolic or endocrine factors. | Altered Mental Status Coma Delirium and Psychosis. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. MRI Head Without and With IV Contrast MRI is the imaging test of choice in the evaluation of suspected progressive inflammatory conditions, such as multiple sclerosis or neuropsychiatric systemic lupus erythematosus. In the assessment of known ICH, MRI is usually not required unless there is suspicion for an underlying mass or lesion or if axonal shear injury is suspected. MRI without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected. MRI Head Without IV Contrast MRI is complementary to CT in the evaluation of suspected progression of intracranial mass lesions, infection, and ischemia and may be performed as a first-line test instead of CT. However, the literature search did not identify any studies regarding the use of MRI in the evaluation of acute or worsening mental status changes in a patient with known intracranial pathology. Advantages of MRI include higher sensitivity for the detection of ischemia, encephalitis, subtle cases of SAH, and enhancement of pathology compared with CT and the potential to use advanced imaging applications that may provide critical information, such as diffusion-weighted imaging, MR perfusion, susceptibility-weighted sequences, and MR spectroscopy. Disadvantages of MRI include longer examination time, susceptibility to motion artifacts, and implanted devices that are not MRI safe [2]. Variant 3: Adult. Altered mental status. Suspected medical illness or toxic-metabolic cause. Initial imaging. Acute mental status changes may be triggered by a wide range of medical conditions, including drugs and intoxication, system or organ dysfunction, and metabolic or endocrine factors. | 3102409 |
acrac_3102409_9 | Altered Mental Status Coma Delirium and Psychosis | This variant encompasses a subgroup of patients presenting with acute mental status changes at low risk of acute intracranial pathology. CT Head With IV Contrast The literature search did not identify any studies regarding the use of contrast-enhanced CT relevant to this variant, and contrast-enhanced CT examinations are not performed as a first-line test in this setting. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. CT Head Without IV Contrast ED physicians are moderately accurate at establishing the correct clinical diagnosis for the cause of AMS within the first 20 minutes of the patient encounter [15]. A large proportion of misdiagnoses in this study were deemed insignificant because of confusing various forms of isolated or mixed intoxication. Although CT head may be useful in this scenario, deferring head CT imaging while observing if intoxicated patients symptomatically improve may be a safe practice and may prevent the need for imaging in large percentage of intoxicated patients [39]. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. MRI Head Without and With IV Contrast There is no relevant literature to support the use of MRI head without and with IV contrast in this clinical scenario. | Altered Mental Status Coma Delirium and Psychosis. This variant encompasses a subgroup of patients presenting with acute mental status changes at low risk of acute intracranial pathology. CT Head With IV Contrast The literature search did not identify any studies regarding the use of contrast-enhanced CT relevant to this variant, and contrast-enhanced CT examinations are not performed as a first-line test in this setting. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. CT Head Without IV Contrast ED physicians are moderately accurate at establishing the correct clinical diagnosis for the cause of AMS within the first 20 minutes of the patient encounter [15]. A large proportion of misdiagnoses in this study were deemed insignificant because of confusing various forms of isolated or mixed intoxication. Although CT head may be useful in this scenario, deferring head CT imaging while observing if intoxicated patients symptomatically improve may be a safe practice and may prevent the need for imaging in large percentage of intoxicated patients [39]. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. MRI Head Without and With IV Contrast There is no relevant literature to support the use of MRI head without and with IV contrast in this clinical scenario. | 3102409 |
acrac_3102409_10 | Altered Mental Status Coma Delirium and Psychosis | MRI Head Without IV Contrast There may be unique instances where a brain MRI examination may be useful in confirming a suspected clinical diagnosis responsible for AMS, such as carbon monoxide poisoning, Wernicke encephalopathy (thiamine deficiency) [40], drug toxicity including medications (eg, methotrexate, metronidazole) and illegal drug use, central pontine myelinolysis, or additional metabolic disorders. However, the literature search did not identify any studies regarding the use of MRI relevant to this variant. Altered Mental Status, Coma, Delirium, and Psychosis Variant 4: Adult. Altered mental status despite clinical management of known medical illness or toxic- metabolic cause. Initial imaging. This is a challenging clinical scenario in which common and treatable causes of AMS have been deemed unlikely, and a more exhaustive evaluation is required to find the precipitating cause of AMS. Clinical suspicion for a neurologic cause of AMS may be in an intermediate category. CT Head With IV Contrast Contrast-enhanced CT examinations are usually not performed as a first-line test in this setting but may be considered as a second-line test to assess abnormalities found on the screening head CT and for patients unable or unwilling to have MRI [28]. Evidence guiding appropriate imaging recommendations in this variant is limited because most studies in the literature search sampled undifferentiated patient populations with a broad range of risk factors and are not directly applicable to this variant [2,29,31-33]. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. | Altered Mental Status Coma Delirium and Psychosis. MRI Head Without IV Contrast There may be unique instances where a brain MRI examination may be useful in confirming a suspected clinical diagnosis responsible for AMS, such as carbon monoxide poisoning, Wernicke encephalopathy (thiamine deficiency) [40], drug toxicity including medications (eg, methotrexate, metronidazole) and illegal drug use, central pontine myelinolysis, or additional metabolic disorders. However, the literature search did not identify any studies regarding the use of MRI relevant to this variant. Altered Mental Status, Coma, Delirium, and Psychosis Variant 4: Adult. Altered mental status despite clinical management of known medical illness or toxic- metabolic cause. Initial imaging. This is a challenging clinical scenario in which common and treatable causes of AMS have been deemed unlikely, and a more exhaustive evaluation is required to find the precipitating cause of AMS. Clinical suspicion for a neurologic cause of AMS may be in an intermediate category. CT Head With IV Contrast Contrast-enhanced CT examinations are usually not performed as a first-line test in this setting but may be considered as a second-line test to assess abnormalities found on the screening head CT and for patients unable or unwilling to have MRI [28]. Evidence guiding appropriate imaging recommendations in this variant is limited because most studies in the literature search sampled undifferentiated patient populations with a broad range of risk factors and are not directly applicable to this variant [2,29,31-33]. CT Head Without and With IV Contrast A common practice is to perform a noncontrast screening head CT followed by a more sensitive MRI brain examination performed with and without IV contrast in the setting of AMS. There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. | 3102409 |
acrac_3102409_11 | Altered Mental Status Coma Delirium and Psychosis | MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. MRI Head Without and With IV Contrast MRI examinations without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected. However, the literature search did not identify any studies regarding the use of contrast-enhanced MRI relevant to this variant. Noncontrast MRI examinations of the brain are usually sufficient in the assessment of intracranial complications related to hypertensive emergency, including posterior reversible encephalopathy syndrome. Variant 5: Adult. New onset psychosis. Initial imaging. This variant addresses the role of neuroimaging in the assessment for secondary causes of new onset psychosis in the ED or inpatient setting. Some of the reported organic causes of psychosis include tumors or infarcts in specific areas of the brain, such as the temporal lobe, systemic lupus erythematosus, encephalitis, multiple sclerosis, Wilson disease, Huntington disease, or metachromatic leukodystrophy [42-44]. Patients with new onset psychosis who have suspected stroke, focal neurologic deficit, seizure, head trauma, or headache should refer to the respective ACR Appropriateness Criteria as appropriate: ACR Appropriateness CT Head With IV Contrast Contrast-enhanced CT is generally not helpful for new onset psychosis in the absence of focal neurologic deficits. CT Head Without and With IV Contrast There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. | Altered Mental Status Coma Delirium and Psychosis. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. MRI Head Without and With IV Contrast MRI examinations without and with IV contrast may be performed if intracranial infection, tumor, inflammatory lesions, or vascular pathologies are suspected. However, the literature search did not identify any studies regarding the use of contrast-enhanced MRI relevant to this variant. Noncontrast MRI examinations of the brain are usually sufficient in the assessment of intracranial complications related to hypertensive emergency, including posterior reversible encephalopathy syndrome. Variant 5: Adult. New onset psychosis. Initial imaging. This variant addresses the role of neuroimaging in the assessment for secondary causes of new onset psychosis in the ED or inpatient setting. Some of the reported organic causes of psychosis include tumors or infarcts in specific areas of the brain, such as the temporal lobe, systemic lupus erythematosus, encephalitis, multiple sclerosis, Wilson disease, Huntington disease, or metachromatic leukodystrophy [42-44]. Patients with new onset psychosis who have suspected stroke, focal neurologic deficit, seizure, head trauma, or headache should refer to the respective ACR Appropriateness Criteria as appropriate: ACR Appropriateness CT Head With IV Contrast Contrast-enhanced CT is generally not helpful for new onset psychosis in the absence of focal neurologic deficits. CT Head Without and With IV Contrast There is no relevant literature to support the use of CT head without and with IV contrast in the initial imaging of this clinical scenario. MRI Head With IV Contrast There is no relevant literature to support the use of MRI head performed only with IV contrast in this clinical scenario. | 3102409 |
acrac_69438_0 | Fever Without Source or Unknown Origin Child | Although FWS is mostly self-limited and of little clinical concern, the burden on clinicians is to decide which children actually have a serious bacterial infection (SBI) that requires antibiotic treatment and even hospitalization [18,19]. Febrile neonates are at higher risk; the reported incidence of SBI in all febrile neonates presenting to emergency departments varies between 6% and 28% [17,20]. In children, the usual sources/causes of SBI are urinary tract infection, pneumonia, bloodstream infection, and meningitis. With the advent of vaccines for the most common pathogenic serotypes of H. flu and S. pneumonia, the incidence of SBI has dropped significantly [2,3,6,10,13,14]. Although it is implied by the definition of FWS that the etiology of fever is unknown, many studies and guidelines include children with respiratory symptoms [2,3,5,6,8,16,21-24]. For this reason, we were compelled to include in our guidelines for FWS children with respiratory symptoms. Overview of Imaging Modalities A detailed and thorough history and physical examination is the most important component of the diagnostic evaluation of a child with FWS or FUO. Chest radiographs have a role in evaluation of occult pneumonia and should be performed in neonates with FWS and respiratory symptoms and in selected older children with high Reprint requests to: [email protected] Discussion of Imaging Modalities by Variant Variants 1 and 2: Neonate younger than 1 month of age with FWS. In febrile neonates younger than 28 days, history and physical examination alone may not be able to completely exclude SBI, even in children who appear clinically well or mildly ill [40]. Therefore, a full sepsis workup is frequently performed. This includes complete blood count, blood culture, urinalysis and urine culture, lumbar puncture with evaluation of cerebrospinal fluid, and administration of antibiotics in the emergency department, followed by hospitalization pending results of cultures [2,3,8,9,22,28]. | Fever Without Source or Unknown Origin Child. Although FWS is mostly self-limited and of little clinical concern, the burden on clinicians is to decide which children actually have a serious bacterial infection (SBI) that requires antibiotic treatment and even hospitalization [18,19]. Febrile neonates are at higher risk; the reported incidence of SBI in all febrile neonates presenting to emergency departments varies between 6% and 28% [17,20]. In children, the usual sources/causes of SBI are urinary tract infection, pneumonia, bloodstream infection, and meningitis. With the advent of vaccines for the most common pathogenic serotypes of H. flu and S. pneumonia, the incidence of SBI has dropped significantly [2,3,6,10,13,14]. Although it is implied by the definition of FWS that the etiology of fever is unknown, many studies and guidelines include children with respiratory symptoms [2,3,5,6,8,16,21-24]. For this reason, we were compelled to include in our guidelines for FWS children with respiratory symptoms. Overview of Imaging Modalities A detailed and thorough history and physical examination is the most important component of the diagnostic evaluation of a child with FWS or FUO. Chest radiographs have a role in evaluation of occult pneumonia and should be performed in neonates with FWS and respiratory symptoms and in selected older children with high Reprint requests to: [email protected] Discussion of Imaging Modalities by Variant Variants 1 and 2: Neonate younger than 1 month of age with FWS. In febrile neonates younger than 28 days, history and physical examination alone may not be able to completely exclude SBI, even in children who appear clinically well or mildly ill [40]. Therefore, a full sepsis workup is frequently performed. This includes complete blood count, blood culture, urinalysis and urine culture, lumbar puncture with evaluation of cerebrospinal fluid, and administration of antibiotics in the emergency department, followed by hospitalization pending results of cultures [2,3,8,9,22,28]. | 69438 |
acrac_69438_1 | Fever Without Source or Unknown Origin Child | A chest radiograph is indicated in neonates with FWS and respiratory symptoms [3,21]. In addition, a chest radiograph in a septic-appearing neonate with FWS may disclose an occult pneumonia [6,8,16,28]. Some investigators advocate routine chest radiographs in all neonates with FWS because these infants are relatively immunocompromised compared with older infants and children, and the consequences of a missed SBI or occult infection are felt to be greater [6]. A chest radiograph can help exclude congenital or acquired cardiac disease in a child who is febrile and ill. However, the benefit of routine use of chest radiography in neonates without respiratory symptoms has not been established [3,21]. Bramson et al [43] combined their data with those of 2 prior studies [42,47] and subjected these to a statistical meta-analysis. The larger number of patients in the combined study allowed more valid conclusions concerning the accepted practice of performing chest radiographs in febrile infants as part of the sepsis workup. These 3 series had 671 infants. In 361 infants with no clinical evidence of pulmonary disease on history and physical examination, all had normal chest radiographs. A finding of only hyperinflation on a chest radiograph was interpreted as normal because it was felt that the infants would likely have a viral illness or reactive airway disease and would not usually be receiving antibiotics, unlike older children and adults [48]. Bramson et al [43] indicated that a chest radiograph in a patient with no pulmonary symptoms or signs would be positive <1.2% of the time. In the current era of S. pneumonia and H. flu vaccine use, this rate might fall even further. Murphy et al [49] found an incidence of radiographic pneumonia in 5.3% of 2,128 children under 10 years of age with no lower respiratory symptoms (other than cough) and concluded that there was a low utility in obtaining chest radiographs in febrile children without cough. | Fever Without Source or Unknown Origin Child. A chest radiograph is indicated in neonates with FWS and respiratory symptoms [3,21]. In addition, a chest radiograph in a septic-appearing neonate with FWS may disclose an occult pneumonia [6,8,16,28]. Some investigators advocate routine chest radiographs in all neonates with FWS because these infants are relatively immunocompromised compared with older infants and children, and the consequences of a missed SBI or occult infection are felt to be greater [6]. A chest radiograph can help exclude congenital or acquired cardiac disease in a child who is febrile and ill. However, the benefit of routine use of chest radiography in neonates without respiratory symptoms has not been established [3,21]. Bramson et al [43] combined their data with those of 2 prior studies [42,47] and subjected these to a statistical meta-analysis. The larger number of patients in the combined study allowed more valid conclusions concerning the accepted practice of performing chest radiographs in febrile infants as part of the sepsis workup. These 3 series had 671 infants. In 361 infants with no clinical evidence of pulmonary disease on history and physical examination, all had normal chest radiographs. A finding of only hyperinflation on a chest radiograph was interpreted as normal because it was felt that the infants would likely have a viral illness or reactive airway disease and would not usually be receiving antibiotics, unlike older children and adults [48]. Bramson et al [43] indicated that a chest radiograph in a patient with no pulmonary symptoms or signs would be positive <1.2% of the time. In the current era of S. pneumonia and H. flu vaccine use, this rate might fall even further. Murphy et al [49] found an incidence of radiographic pneumonia in 5.3% of 2,128 children under 10 years of age with no lower respiratory symptoms (other than cough) and concluded that there was a low utility in obtaining chest radiographs in febrile children without cough. | 69438 |
acrac_69438_2 | Fever Without Source or Unknown Origin Child | A longer duration of cough, fever, and leukocytosis increased the likelihood of radiographic pneumonia in these children. The practice of routinely obtaining a chest radiograph has been challenged. Korones et al [61] evaluated 54 children with cancer who were hospitalized for hundreds of episodes of fever and neutropenia. They found an incidence of radiographic pneumonia of only 3% to 6%. The children without respiratory findings had no evidence of pneumonia on chest radiographs, and children who did not have chest radiographs showed no significant outcome differences from those who did. Philips et al [62] confirmed in a meta-analysis the low use of routine chest radiographs in this setting but stated that in those with a predisposition to pneumonia and those not responding to a short empiric course of antibiotics, chest radiographs should be performed despite the absence of clinical signs of a lower respiratory tract infection. Children with neutropenia and FWS often undergo advanced imaging, but there is little evidence-based data about which studies are most efficacious. In their 2002 guidelines (not pediatric specific), the Infectious Diseases Society of America noted that one-half of febrile neutropenic patients with normal chest radiographs will have evidence of pneumonia on chest CT [63]. Archibald et al [36] evaluated the performance of CT in 83 neutropenic pediatric cancer patients who had 109 instances of fever lasting 4 days or more. Rates of positive CT findings varied by body region: head and neck, 8%; paranasal sinus, 41%; chest, 49%; and abdomen, 19%. Findings on paranasal sinus and chest CT led to changes in therapy in 24% and 30% of cases, respectively. However, they added that CT was rarely abnormal in the absence of localizing signs or symptoms and that in the absence of symptoms, CT findings rarely lead to therapeutic changes. | Fever Without Source or Unknown Origin Child. A longer duration of cough, fever, and leukocytosis increased the likelihood of radiographic pneumonia in these children. The practice of routinely obtaining a chest radiograph has been challenged. Korones et al [61] evaluated 54 children with cancer who were hospitalized for hundreds of episodes of fever and neutropenia. They found an incidence of radiographic pneumonia of only 3% to 6%. The children without respiratory findings had no evidence of pneumonia on chest radiographs, and children who did not have chest radiographs showed no significant outcome differences from those who did. Philips et al [62] confirmed in a meta-analysis the low use of routine chest radiographs in this setting but stated that in those with a predisposition to pneumonia and those not responding to a short empiric course of antibiotics, chest radiographs should be performed despite the absence of clinical signs of a lower respiratory tract infection. Children with neutropenia and FWS often undergo advanced imaging, but there is little evidence-based data about which studies are most efficacious. In their 2002 guidelines (not pediatric specific), the Infectious Diseases Society of America noted that one-half of febrile neutropenic patients with normal chest radiographs will have evidence of pneumonia on chest CT [63]. Archibald et al [36] evaluated the performance of CT in 83 neutropenic pediatric cancer patients who had 109 instances of fever lasting 4 days or more. Rates of positive CT findings varied by body region: head and neck, 8%; paranasal sinus, 41%; chest, 49%; and abdomen, 19%. Findings on paranasal sinus and chest CT led to changes in therapy in 24% and 30% of cases, respectively. However, they added that CT was rarely abnormal in the absence of localizing signs or symptoms and that in the absence of symptoms, CT findings rarely lead to therapeutic changes. | 69438 |
acrac_69438_3 | Fever Without Source or Unknown Origin Child | In a more recent study, Agrawal et al [35] demonstrated a similar distribution of positive findings among body regions but found that only 2 of the initial positive CT scans led to a change in management (6.5% of positive scans, 0.8% of all initial scans). They therefore recommend limiting initial empiric CT imaging to the chest only in patients without localizing signs or symptoms. Regarding the use of FDG-PET/CT, Blokhuis et al [39] found a 78% sensitivity and 67% specificity in 12 of such children. Variant 6: Infant or child more than 1 month of age with fever of unknown origin (FUO). Occult infection is the usual cause of FUO in children and is less commonly due to rheumatologic, autoimmune, neoplastic, or other inflammatory conditions [9,20,24,27,66,67]. Some children never have a specific diagnosis reached [9,24]. Evaluation of FUO in children is mainly based on thorough physical examination, history, and laboratory studies such as a complete blood cell count and peripheral smear, erythrocyte sedimentation rate, C- reactive protein, aerobic blood cultures, urinalysis, urine culture, tuberculin skin test, electrolytes, blood urea nitrogen, creatinine, hepatic enzymes, and human immunodeficiency virus serology [9,20,24,27,68,69]. Chest radiographs are usually obtained to evaluate for occult pneumonia and lymphadenopathy. Although many studies describe the clinical course of such patients, few of them examine the utility of diagnostic imaging modalities in these difficult patients. In general, if a detailed review of the history, physical examination, and screening evaluation fail to suggest a diagnosis, more extensive imaging can be considered. This includes abdominal ultrasound (US) and CT studies of the chest, abdomen, and paranasal sinus [4]. Steele et al [70] evaluated 109 children with FUO with conventional radionuclide techniques. These studies were often positive but rarely led to an unsuspected diagnosis. | Fever Without Source or Unknown Origin Child. In a more recent study, Agrawal et al [35] demonstrated a similar distribution of positive findings among body regions but found that only 2 of the initial positive CT scans led to a change in management (6.5% of positive scans, 0.8% of all initial scans). They therefore recommend limiting initial empiric CT imaging to the chest only in patients without localizing signs or symptoms. Regarding the use of FDG-PET/CT, Blokhuis et al [39] found a 78% sensitivity and 67% specificity in 12 of such children. Variant 6: Infant or child more than 1 month of age with fever of unknown origin (FUO). Occult infection is the usual cause of FUO in children and is less commonly due to rheumatologic, autoimmune, neoplastic, or other inflammatory conditions [9,20,24,27,66,67]. Some children never have a specific diagnosis reached [9,24]. Evaluation of FUO in children is mainly based on thorough physical examination, history, and laboratory studies such as a complete blood cell count and peripheral smear, erythrocyte sedimentation rate, C- reactive protein, aerobic blood cultures, urinalysis, urine culture, tuberculin skin test, electrolytes, blood urea nitrogen, creatinine, hepatic enzymes, and human immunodeficiency virus serology [9,20,24,27,68,69]. Chest radiographs are usually obtained to evaluate for occult pneumonia and lymphadenopathy. Although many studies describe the clinical course of such patients, few of them examine the utility of diagnostic imaging modalities in these difficult patients. In general, if a detailed review of the history, physical examination, and screening evaluation fail to suggest a diagnosis, more extensive imaging can be considered. This includes abdominal ultrasound (US) and CT studies of the chest, abdomen, and paranasal sinus [4]. Steele et al [70] evaluated 109 children with FUO with conventional radionuclide techniques. These studies were often positive but rarely led to an unsuspected diagnosis. | 69438 |
acrac_3155410_0 | Imaging after Mastectomy and Breast Reconstruction | Introduction/Background Mastectomy may be performed to treat breast cancer [1] with some authors reporting increasing rates of mastectomy relative to breast conservation in the United States [2-4]. Mastectomy may also be performed as a prophylactic approach in women with a high lifetime risk of developing breast cancer. Mastectomy techniques have changed over time with radical mastectomy replaced by modified radical mastectomy and with options such as skin-sparing and nipple-sparing procedures now available [5]. In addition, mastectomies may be performed with or without reconstruction. Reconstruction approaches differ and may be autologous, involving a transfer of tissue (skin, subcutaneous fat, and muscle) from other parts of the body to the chest wall. Examples of autologous reconstruction include latissimus dorsi flaps, transverse rectus abdominis myocutaneous (TRAM) flaps, and variants such as deep inferior epigastric perforator flaps [1]. Reconstruction may also involve implants. Implant reconstruction may occur as a single procedure or as multistep procedures with initial use of an adjustable tissue expander allowing the mastectomy tissues to be stretched without compromising blood supply. Ultimately, a full-volume implant, which may be saline, silicone, or both, will be placed. Implant reconstruction often involves the placement of acellular matrix, which can increase risk of seroma formation and occasionally is visible on imaging. Reconstructions with a combination of autologous and implant reconstruction may also be performed. Other techniques such as autologous fat grafting may be used to refine both implant and flap-based reconstruction [6]. Although most of the breast tissue is removed after mastectomy, recurrence may occur in residual tissue. The majority of recurrences in the reconstructed breast will be found in the skin and the subcutaneous tissues followed by recurrences deep to the pectoralis muscle [7]. | Imaging after Mastectomy and Breast Reconstruction. Introduction/Background Mastectomy may be performed to treat breast cancer [1] with some authors reporting increasing rates of mastectomy relative to breast conservation in the United States [2-4]. Mastectomy may also be performed as a prophylactic approach in women with a high lifetime risk of developing breast cancer. Mastectomy techniques have changed over time with radical mastectomy replaced by modified radical mastectomy and with options such as skin-sparing and nipple-sparing procedures now available [5]. In addition, mastectomies may be performed with or without reconstruction. Reconstruction approaches differ and may be autologous, involving a transfer of tissue (skin, subcutaneous fat, and muscle) from other parts of the body to the chest wall. Examples of autologous reconstruction include latissimus dorsi flaps, transverse rectus abdominis myocutaneous (TRAM) flaps, and variants such as deep inferior epigastric perforator flaps [1]. Reconstruction may also involve implants. Implant reconstruction may occur as a single procedure or as multistep procedures with initial use of an adjustable tissue expander allowing the mastectomy tissues to be stretched without compromising blood supply. Ultimately, a full-volume implant, which may be saline, silicone, or both, will be placed. Implant reconstruction often involves the placement of acellular matrix, which can increase risk of seroma formation and occasionally is visible on imaging. Reconstructions with a combination of autologous and implant reconstruction may also be performed. Other techniques such as autologous fat grafting may be used to refine both implant and flap-based reconstruction [6]. Although most of the breast tissue is removed after mastectomy, recurrence may occur in residual tissue. The majority of recurrences in the reconstructed breast will be found in the skin and the subcutaneous tissues followed by recurrences deep to the pectoralis muscle [7]. | 3155410 |
acrac_3155410_1 | Imaging after Mastectomy and Breast Reconstruction | Recurrence rates are reported to be approximately 1% to 2% annually for both mastectomy and mastectomy with reconstruction, and overall recurrence has been reported at between 2% to 15% and has been noted to vary based on the initial cancer type and stage as well as follow-up period of the study [5,7-13]. Clinical evaluation has been a mainstay of evaluation of the postmastectomy breast [4], and the appropriate surveillance imaging strategy for patients with a history of mastectomy with or without reconstruction is an evolving topic, with evidence predominantly drawn from small retrospective studies. Finally, women who have undergone mastectomy with or without reconstruction may present with symptomatic concerns, both in the immediate postoperative period and later. Sequalae of the surgery, such as hematomas, infections, and most commonly in the early postoperative period, fat necrosis [7], may present as palpable findings. Recurrent disease may also present as a palpable lump [7,14]. OR aNew York University School of Medicine, New York, New York. bPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. dUniversity of Louisville School of Medicine, Louisville, Kentucky; Society of Surgical Oncology. eUniversity of Cincinnati, Cincinnati, Ohio. fAlpert Medical School of Brown University, Providence, Rhode Island. gNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. hMemorial Sloan Kettering Cancer Center, New York, New York. iUniversity of Michigan, Ann Arbor, Michigan. jBeth Israel Deaconess Medical Center, Boston, Massachusetts. kStamford Hospital, Stamford, Connecticut; American College of Surgeons. lWomen and Infants Hospital, Providence, Rhode Island; American College of Obstetricians and Gynecologists. mRadiology Associates of Tallahassee, Tallahassee, Florida. | Imaging after Mastectomy and Breast Reconstruction. Recurrence rates are reported to be approximately 1% to 2% annually for both mastectomy and mastectomy with reconstruction, and overall recurrence has been reported at between 2% to 15% and has been noted to vary based on the initial cancer type and stage as well as follow-up period of the study [5,7-13]. Clinical evaluation has been a mainstay of evaluation of the postmastectomy breast [4], and the appropriate surveillance imaging strategy for patients with a history of mastectomy with or without reconstruction is an evolving topic, with evidence predominantly drawn from small retrospective studies. Finally, women who have undergone mastectomy with or without reconstruction may present with symptomatic concerns, both in the immediate postoperative period and later. Sequalae of the surgery, such as hematomas, infections, and most commonly in the early postoperative period, fat necrosis [7], may present as palpable findings. Recurrent disease may also present as a palpable lump [7,14]. OR aNew York University School of Medicine, New York, New York. bPanel Chair, Alpert Medical School of Brown University, Providence, Rhode Island. cPanel Vice-Chair, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida. dUniversity of Louisville School of Medicine, Louisville, Kentucky; Society of Surgical Oncology. eUniversity of Cincinnati, Cincinnati, Ohio. fAlpert Medical School of Brown University, Providence, Rhode Island. gNorthwestern University Feinberg School of Medicine, Chicago, Illinois; American College of Physicians. hMemorial Sloan Kettering Cancer Center, New York, New York. iUniversity of Michigan, Ann Arbor, Michigan. jBeth Israel Deaconess Medical Center, Boston, Massachusetts. kStamford Hospital, Stamford, Connecticut; American College of Surgeons. lWomen and Infants Hospital, Providence, Rhode Island; American College of Obstetricians and Gynecologists. mRadiology Associates of Tallahassee, Tallahassee, Florida. | 3155410 |
acrac_3155410_2 | Imaging after Mastectomy and Breast Reconstruction | nCentral Oregon Radiology Associates, Bend, Oregon. oSpecialty Chair, NYU Clinical Cancer Center, New York, New York. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast for screening in this clinical setting. Mammography Screening Annual screening with 2-D mammography or DBT is recommended for the contralateral native breast. There is insufficient evidence to support screening with 2-D mammography of the postmastectomy side. Although one small retrospective study has shown a small increase in cancer detection with mammography in postmastectomy patients [16], another study has demonstrated no benefit [8]. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without intravenous (IV) contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI without and with IV contrast, specifically for screening the postmastectomy nonreconstructed breast. However, based on breast cancer risk, including factors such as age at cancer diagnosis, breast density, and family history, women with a personal history of cancer may undergo MRI for the contralateral native breast [17]. In this setting, the postmastectomy breast may be imaged and evaluated on MRI with potential for malignancy detection and characterization [18]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) for screening in this clinical setting. | Imaging after Mastectomy and Breast Reconstruction. nCentral Oregon Radiology Associates, Bend, Oregon. oSpecialty Chair, NYU Clinical Cancer Center, New York, New York. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] FDG-PET Breast Dedicated There is no relevant literature to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET breast for screening in this clinical setting. Mammography Screening Annual screening with 2-D mammography or DBT is recommended for the contralateral native breast. There is insufficient evidence to support screening with 2-D mammography of the postmastectomy side. Although one small retrospective study has shown a small increase in cancer detection with mammography in postmastectomy patients [16], another study has demonstrated no benefit [8]. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI breast without intravenous (IV) contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is no relevant literature to support the use of MRI without and with IV contrast, specifically for screening the postmastectomy nonreconstructed breast. However, based on breast cancer risk, including factors such as age at cancer diagnosis, breast density, and family history, women with a personal history of cancer may undergo MRI for the contralateral native breast [17]. In this setting, the postmastectomy breast may be imaged and evaluated on MRI with potential for malignancy detection and characterization [18]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi molecular breast imaging (MBI) for screening in this clinical setting. | 3155410 |
acrac_3155410_3 | Imaging after Mastectomy and Breast Reconstruction | US Breast There is insufficient evidence to support the use of ultrasound (US) for screening in this setting. There is a paucity of evidence-based literature [16,18-20], with only a few small retrospective studies finding utility in screening with US in this setting. A subset of a retrospective study evaluated 67 women postmastectomy who had suspected recurrence and underwent US imaging; although some of these women were symptomatic, 7 recurrent impalpable cancers were detected only on US in the cohort [16]. This study also found 3/61 cancers detected only on mammography and not on US. A study of 1,796 US examinations in 874 asymptomatic patients (median follow-up of 37 months) found 15 clinically occult recurrences detected with US in 15 patients (cancer detection rate of 1.7% per patient and 0.8% per examination) [19]. Lee et al [20] evaluated 1,180 consecutive screening USs of the mastectomy site and the ipsilateral axillary fossa in 468 asymptomatic women and found 10 malignancies with a similar cancer detection rate of 2.1% per patient and 0.8% per screening examination. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. Digital Breast Tomosynthesis Screening Although insufficient studies have been performed to assess the utility of DBT in this setting, multiple investigations have demonstrated that DBT is helpful in the screening setting of the native breast, thus decreasing recall rates and increasing cancer detection rates compared to a conventional mammographic workup [21-26]. Mammography Screening Evidence is limited, but a few retrospective studies suggest a benefit to screening women with autologous reconstruction after mastectomy for cancer in the reconstruction side. Helvie et al [27] looked at 214 consecutive screening mammograms in 113 women with TRAM flap reconstructions, 106 (94%) of which were performed after mastectomy for cancer. | Imaging after Mastectomy and Breast Reconstruction. US Breast There is insufficient evidence to support the use of ultrasound (US) for screening in this setting. There is a paucity of evidence-based literature [16,18-20], with only a few small retrospective studies finding utility in screening with US in this setting. A subset of a retrospective study evaluated 67 women postmastectomy who had suspected recurrence and underwent US imaging; although some of these women were symptomatic, 7 recurrent impalpable cancers were detected only on US in the cohort [16]. This study also found 3/61 cancers detected only on mammography and not on US. A study of 1,796 US examinations in 874 asymptomatic patients (median follow-up of 37 months) found 15 clinically occult recurrences detected with US in 15 patients (cancer detection rate of 1.7% per patient and 0.8% per examination) [19]. Lee et al [20] evaluated 1,180 consecutive screening USs of the mastectomy site and the ipsilateral axillary fossa in 468 asymptomatic women and found 10 malignancies with a similar cancer detection rate of 2.1% per patient and 0.8% per screening examination. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. Digital Breast Tomosynthesis Screening Although insufficient studies have been performed to assess the utility of DBT in this setting, multiple investigations have demonstrated that DBT is helpful in the screening setting of the native breast, thus decreasing recall rates and increasing cancer detection rates compared to a conventional mammographic workup [21-26]. Mammography Screening Evidence is limited, but a few retrospective studies suggest a benefit to screening women with autologous reconstruction after mastectomy for cancer in the reconstruction side. Helvie et al [27] looked at 214 consecutive screening mammograms in 113 women with TRAM flap reconstructions, 106 (94%) of which were performed after mastectomy for cancer. | 3155410 |
acrac_3155410_4 | Imaging after Mastectomy and Breast Reconstruction | The cancer detection rate was 0.9% per screen and 1.9% per patient (2/106, 95% confidence interval [CI]: 0.33%, 7.32%) and positive predictive value (PPV) of biopsy was 33% (95% CI: 6%, 76%). Noroozian et al [10] in a larger study of 515 women and 618 mastectomies with reconstruction, 485 of which were performed for cancer, found the cancer detection rate of screening mammography to be 1.5/1,000 screening mammograms, comparable to that for one native breast of age-matched women. However, Freyvogel et al [28] retrospectively evaluated 541 postmastectomy and autologous reconstruction patients. Of these, 397 patients had screening mammography and 537 patients underwent routine clinical examination. Of the patients in the cohort, 26 of 27 (96.3%) had a clinically detectable recurrence, and the two cancers detected on screening were also palpable on follow-up clinical examination. Lee et al [29] evaluated 554 mammograms (265 TRAM flap reconstructions); no cancers were detected through screening and no interval nonpalpable recurrent breast cancers missed at mammography were identified, yielding a 0% rate of detection (exact 95% CI: 0.0%, 1.4%). The authors concluded that screening this population is less effective than screening average-risk women in their 40s, although it should be noted that the upper end of the CI is in line with the rates reported by the other studies mentioned above. Of note, there are no studies specifically evaluating decrease in mortality from screening women in this setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI of the breast without IV contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI without and with IV contrast for screening in this setting. | Imaging after Mastectomy and Breast Reconstruction. The cancer detection rate was 0.9% per screen and 1.9% per patient (2/106, 95% confidence interval [CI]: 0.33%, 7.32%) and positive predictive value (PPV) of biopsy was 33% (95% CI: 6%, 76%). Noroozian et al [10] in a larger study of 515 women and 618 mastectomies with reconstruction, 485 of which were performed for cancer, found the cancer detection rate of screening mammography to be 1.5/1,000 screening mammograms, comparable to that for one native breast of age-matched women. However, Freyvogel et al [28] retrospectively evaluated 541 postmastectomy and autologous reconstruction patients. Of these, 397 patients had screening mammography and 537 patients underwent routine clinical examination. Of the patients in the cohort, 26 of 27 (96.3%) had a clinically detectable recurrence, and the two cancers detected on screening were also palpable on follow-up clinical examination. Lee et al [29] evaluated 554 mammograms (265 TRAM flap reconstructions); no cancers were detected through screening and no interval nonpalpable recurrent breast cancers missed at mammography were identified, yielding a 0% rate of detection (exact 95% CI: 0.0%, 1.4%). The authors concluded that screening this population is less effective than screening average-risk women in their 40s, although it should be noted that the upper end of the CI is in line with the rates reported by the other studies mentioned above. Of note, there are no studies specifically evaluating decrease in mortality from screening women in this setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI of the breast without IV contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI without and with IV contrast for screening in this setting. | 3155410 |
acrac_3155410_5 | Imaging after Mastectomy and Breast Reconstruction | Based on breast cancer risk, including factors such as age at cancer diagnosis, breast density, and family history, women with a personal history of cancer may undergo MRI for the contralateral native breast [17]. In this setting, MRI will also allow for evaluation of the reconstructed breast and may be able to demonstrate recurrent malignancy, although the literature is scant with only several small studies and case reports [30,31]. Reiber et al [31], for example, used MRI to evaluate 41 patients with flap reconstructions, finding one mammographically and sonographically occult cancer in a patient with a latissimus dorsi flap. However, MRI also generated three false- positive biopsies. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Imaging after Mastectomy and Breast Reconstruction Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of mammography for screening in this clinical setting. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. | Imaging after Mastectomy and Breast Reconstruction. Based on breast cancer risk, including factors such as age at cancer diagnosis, breast density, and family history, women with a personal history of cancer may undergo MRI for the contralateral native breast [17]. In this setting, MRI will also allow for evaluation of the reconstructed breast and may be able to demonstrate recurrent malignancy, although the literature is scant with only several small studies and case reports [30,31]. Reiber et al [31], for example, used MRI to evaluate 41 patients with flap reconstructions, finding one mammographically and sonographically occult cancer in a patient with a latissimus dorsi flap. However, MRI also generated three false- positive biopsies. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Imaging after Mastectomy and Breast Reconstruction Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of mammography for screening in this clinical setting. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. | 3155410 |
acrac_3155410_6 | Imaging after Mastectomy and Breast Reconstruction | Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of mammography for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI without and with IV contrast for breast cancer screening in this setting. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is insufficient evidence to support the use of mammography for breast cancer screening in this population. A recent study by Noroozian et al [10] found no evidence to support the use of screening mammography in women who had undergone bilateral prophylactic mastectomy with autologous reconstruction. Of 133 prophylactic mastectomies with autologous reconstruction (805 mammograms), the cancer detection rate with mammography was 0%. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. | Imaging after Mastectomy and Breast Reconstruction. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of mammography for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence to support the use of MRI without and with IV contrast for breast cancer screening in this setting. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is insufficient evidence to support the use of mammography for breast cancer screening in this population. A recent study by Noroozian et al [10] found no evidence to support the use of screening mammography in women who had undergone bilateral prophylactic mastectomy with autologous reconstruction. Of 133 prophylactic mastectomies with autologous reconstruction (805 mammograms), the cancer detection rate with mammography was 0%. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. | 3155410 |
acrac_3155410_7 | Imaging after Mastectomy and Breast Reconstruction | MRI Breast Without and With IV Contrast Although there may be residual breast glandular tissue after mastectomy and MRI may be useful in delineating the amount of this residual tissue in women after prophylactic mastectomy [35], there is insufficient evidence to support the use of MRI breast without and with IV contrast for breast cancer screening in this population. A small retrospective study of breast MRI surveillance examinations performed in a subset of women who underwent bilateral mastectomy for either cancer or prophylaxis and had either implant, flap, or mixed reconstructions found no cancers that were not also evident on clinical examinations [33]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of mammography for screening in this clinical setting. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence to support screening for women with prophylactic mastectomy and implant reconstruction. It has been suggested that the yield of screening in this setting is especially low in the setting of retropectoral implant placement, in which recurrences are most likely to be clinically palpable [33,34]. | Imaging after Mastectomy and Breast Reconstruction. MRI Breast Without and With IV Contrast Although there may be residual breast glandular tissue after mastectomy and MRI may be useful in delineating the amount of this residual tissue in women after prophylactic mastectomy [35], there is insufficient evidence to support the use of MRI breast without and with IV contrast for breast cancer screening in this population. A small retrospective study of breast MRI surveillance examinations performed in a subset of women who underwent bilateral mastectomy for either cancer or prophylaxis and had either implant, flap, or mixed reconstructions found no cancers that were not also evident on clinical examinations [33]. Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Digital Breast Tomosynthesis Screening There is no relevant literature to support the use of DBT for screening in this clinical setting. Mammography Screening There is no relevant literature to support the use of mammography for screening in this clinical setting. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast for screening in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast for screening in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence to support screening for women with prophylactic mastectomy and implant reconstruction. It has been suggested that the yield of screening in this setting is especially low in the setting of retropectoral implant placement, in which recurrences are most likely to be clinically palpable [33,34]. | 3155410 |
acrac_3155410_8 | Imaging after Mastectomy and Breast Reconstruction | A small retrospective study of breast MRI in 48 women status post bilateral mastectomy with and without reconstruction, some of whom underwent surveillance MRI, found no malignancy that was not also evident on clinical examination [33]. A retrospective study of 159 women status post bilateral mastectomy and reconstruction and undergoing MRI surveillance found no cancers in the subset of 31 women who had mastectomy performed for risk reduction [34]. Imaging after Mastectomy and Breast Reconstruction Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Variant 7: Female. Palpable lump or clinically significant pain on the side of the mastectomy without reconstruction. Initial imaging. Digital Breast Tomosynthesis Diagnostic There is insufficient evidence to support the use of DBT as the initial imaging modality in women with palpable lumps or clinically significant pain on the side of the mastectomy. However, DBT can be useful in the diagnostic setting. It is known to improve lesion characterization in noncalcified lesions and to improve cancer detection when compared to conventional mammographic workup [36-38]. Mammography Diagnostic There is limited evidence to support the use of diagnostic mammography as the initial imaging modality in this clinical setting. A study of 67 women who underwent mastectomy and were suspected of recurrence found 3/61 cancers detected only on mammography and not on US [16]. Another study evaluating palpable lumps in 101 patients who had undergone mastectomy, the majority of whom (69%) had reconstruction with implants, demonstrated that mammography could be useful to confirm benign findings such as fat necrosis and benign calcifications identified on US [39]. However, diagnostic mammography yielded no additional cancers beyond those depicted on US. | Imaging after Mastectomy and Breast Reconstruction. A small retrospective study of breast MRI in 48 women status post bilateral mastectomy with and without reconstruction, some of whom underwent surveillance MRI, found no malignancy that was not also evident on clinical examination [33]. A retrospective study of 159 women status post bilateral mastectomy and reconstruction and undergoing MRI surveillance found no cancers in the subset of 31 women who had mastectomy performed for risk reduction [34]. Imaging after Mastectomy and Breast Reconstruction Sestamibi MBI There is no relevant literature to support the use of Tc-99m sestamibi MBI for screening in this clinical setting. US Breast There is no relevant literature to support the use of US for screening in this clinical setting. Variant 7: Female. Palpable lump or clinically significant pain on the side of the mastectomy without reconstruction. Initial imaging. Digital Breast Tomosynthesis Diagnostic There is insufficient evidence to support the use of DBT as the initial imaging modality in women with palpable lumps or clinically significant pain on the side of the mastectomy. However, DBT can be useful in the diagnostic setting. It is known to improve lesion characterization in noncalcified lesions and to improve cancer detection when compared to conventional mammographic workup [36-38]. Mammography Diagnostic There is limited evidence to support the use of diagnostic mammography as the initial imaging modality in this clinical setting. A study of 67 women who underwent mastectomy and were suspected of recurrence found 3/61 cancers detected only on mammography and not on US [16]. Another study evaluating palpable lumps in 101 patients who had undergone mastectomy, the majority of whom (69%) had reconstruction with implants, demonstrated that mammography could be useful to confirm benign findings such as fat necrosis and benign calcifications identified on US [39]. However, diagnostic mammography yielded no additional cancers beyond those depicted on US. | 3155410 |
acrac_3155410_9 | Imaging after Mastectomy and Breast Reconstruction | FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast in this clinical setting. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast without and with IV contrast as the initial imaging modality in women with palpable lump or clinically significant pain on the mastectomy side. However, MRI may help characterize malignancy once identified and has been found to be more accurate than US in delineating extent of disease, although there is a paucity of evidence-based literature [18]. Sestamibi MBI There are a few small retrospective studies evaluating the use of Tc-99m sestamibi MBI in the context of a clinically suspicious lump. For example, Usmani et al [40] looked at 41 consecutive postmastectomy patients and found a sensitivity of 89%, specificity of 92%, PPV of 96%, negative predictive value (NPV) of 80%, and accuracy of 90% with Tc-99m sestamibi MBI. This was compared to US, which had a lower sensitivity of 86%, specificity of 77%, PPV of 89%, NPV of 71%, and accuracy of 83% (P = . 001). The authors found that the combined sensitivity was 100%, specificity 77%, PPV 90%, NPV 100%, and accuracy 93%. However, there is insufficient evidence to support the use of Tc-99m sestamibi MBI as the initial imaging modality in this setting. US Breast A retrospective evaluation of 118 palpable lumps in 101 patients, 9% of whom were status postmastectomy found 13 cancers in the mastectomy bed in women with a history of cancer. US had a high NPV of 97% and a PPV of 27% [39]. Gweon et al [41] evaluated both palpable and nonpalpable US BI-RADS categorization of lesions 4a and above at the mastectomy site and found 9/20 (45%) malignancies among palpable lesions; they also found that 100% of all BI-RADS 4c and BI-RADS 5 lesions proved to be malignant. | Imaging after Mastectomy and Breast Reconstruction. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast in this clinical setting. MRI Breast Without IV Contrast There is no relevant literature to support the use of MRI without IV contrast in this clinical setting. MRI Breast Without and With IV Contrast There is no evidence to support the use of MRI breast without and with IV contrast as the initial imaging modality in women with palpable lump or clinically significant pain on the mastectomy side. However, MRI may help characterize malignancy once identified and has been found to be more accurate than US in delineating extent of disease, although there is a paucity of evidence-based literature [18]. Sestamibi MBI There are a few small retrospective studies evaluating the use of Tc-99m sestamibi MBI in the context of a clinically suspicious lump. For example, Usmani et al [40] looked at 41 consecutive postmastectomy patients and found a sensitivity of 89%, specificity of 92%, PPV of 96%, negative predictive value (NPV) of 80%, and accuracy of 90% with Tc-99m sestamibi MBI. This was compared to US, which had a lower sensitivity of 86%, specificity of 77%, PPV of 89%, NPV of 71%, and accuracy of 83% (P = . 001). The authors found that the combined sensitivity was 100%, specificity 77%, PPV 90%, NPV 100%, and accuracy 93%. However, there is insufficient evidence to support the use of Tc-99m sestamibi MBI as the initial imaging modality in this setting. US Breast A retrospective evaluation of 118 palpable lumps in 101 patients, 9% of whom were status postmastectomy found 13 cancers in the mastectomy bed in women with a history of cancer. US had a high NPV of 97% and a PPV of 27% [39]. Gweon et al [41] evaluated both palpable and nonpalpable US BI-RADS categorization of lesions 4a and above at the mastectomy site and found 9/20 (45%) malignancies among palpable lesions; they also found that 100% of all BI-RADS 4c and BI-RADS 5 lesions proved to be malignant. | 3155410 |
acrac_3155410_10 | Imaging after Mastectomy and Breast Reconstruction | In the event of an indeterminate US finding or an US finding suggestive of fat necrosis, diagnostic mammography or DBT may be helpful for lesion characterization and may preclude the need for biopsy if a clearly benign finding such as an oil cyst is identified. Imaging after Mastectomy and Breast Reconstruction Digital Breast Tomosynthesis Diagnostic There is insufficient evidence to support the use of DBT as the initial imaging modality for women with palpable lumps or clinically significant pain on the side of the mastectomy with reconstruction. However, DBT can be useful in the diagnostic setting. It is known to improve lesion characterization in noncalcified lesions and to improve cancer detection when compared to conventional mammographic workup [36-38]. Mammography Diagnostic There is limited evidence to support the use of diagnostic mammography as the initial imaging modality in this clinical setting. Mammography may be helpful in identifying a benign postsurgical etiology of a palpable concern such as fat necrosis or oil cyst. For example, a study evaluating palpable lumps in 101 patients who had undergone mastectomy, the majority of whom (69%) had reconstruction with implants, demonstrated that mammography could be useful to confirm benign findings such as fat necrosis and benign calcifications identified on US [39]. However, the study also showed that diagnostic mammography yielded no additional cancers beyond those depicted on US. In another small study, Edeiken et al [42] found that mammography depicted only 14 of 25 (56%) of the recurrences visualized on US in women who had undergone autogenous myocutaneous flaps after mastectomy. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast as the initial imaging modality in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence for MRI without and with IV contrast as the initial imaging modality in this setting. | Imaging after Mastectomy and Breast Reconstruction. In the event of an indeterminate US finding or an US finding suggestive of fat necrosis, diagnostic mammography or DBT may be helpful for lesion characterization and may preclude the need for biopsy if a clearly benign finding such as an oil cyst is identified. Imaging after Mastectomy and Breast Reconstruction Digital Breast Tomosynthesis Diagnostic There is insufficient evidence to support the use of DBT as the initial imaging modality for women with palpable lumps or clinically significant pain on the side of the mastectomy with reconstruction. However, DBT can be useful in the diagnostic setting. It is known to improve lesion characterization in noncalcified lesions and to improve cancer detection when compared to conventional mammographic workup [36-38]. Mammography Diagnostic There is limited evidence to support the use of diagnostic mammography as the initial imaging modality in this clinical setting. Mammography may be helpful in identifying a benign postsurgical etiology of a palpable concern such as fat necrosis or oil cyst. For example, a study evaluating palpable lumps in 101 patients who had undergone mastectomy, the majority of whom (69%) had reconstruction with implants, demonstrated that mammography could be useful to confirm benign findings such as fat necrosis and benign calcifications identified on US [39]. However, the study also showed that diagnostic mammography yielded no additional cancers beyond those depicted on US. In another small study, Edeiken et al [42] found that mammography depicted only 14 of 25 (56%) of the recurrences visualized on US in women who had undergone autogenous myocutaneous flaps after mastectomy. FDG-PET Breast Dedicated There is no relevant literature to support the use of FDG-PET breast as the initial imaging modality in this clinical setting. MRI Breast Without and With IV Contrast There is insufficient evidence for MRI without and with IV contrast as the initial imaging modality in this setting. | 3155410 |
acrac_69418_0 | Acute Hand and Wrist Trauma | Introduction/Background Hand injuries account for approximately 20% of emergency department visits [1]. According to the National Hospital Ambulatory Medical Care Survey, 1.5% of all emergency department visits involve hand and wrist fractures. Distal radius fractures are especially common, accounting for up to 18% of fractures in the elderly [2,3]. Because of increasing rates of osteoporosis, the incidence of distal radius fractures has been increasing [4]. Although most distal radius fractures in elderly patients are managed nonoperatively, the use of internal fixation is increasing. Internal fixation has a much higher cost than nonoperative treatment as well as increased rates of hospitalization [5]. For most patients with trauma to the hand and wrist, conventional radiographs provide sufficient diagnostic information to guide the treating physician. However, delayed diagnosis is common because distal radius and scaphoid fractures may be radiographically occult [6]. When initial radiographs are normal but there is high clinical suspicion for fracture, further imaging with additional radiographic projections, CT, or MRI is appropriate. If associated soft-tissue injury is clinically suspected, CT, CT arthrography, MRI, MR arthrography, or ultrasound (US) may be indicated [7-10]. Successful treatment of distal radius fractures requires restoration of radial length, inclination, and tilt, as well as the realignment of the articular fracture fragments [9,11]. The presence of a coronally oriented fracture line, die- punch depression, or more than three articular fracture fragments are common indications for operative reduction [8]. Operative fixation resulting in <2 mm of residual articular surface step-off is usually considered necessary to avoid long-term complications, such as osteoarthritis [9,12]. A standard 3-view radiographic examination of the hand shows most fractures and dislocations of the metacarpals and phalanges [13]. | Acute Hand and Wrist Trauma. Introduction/Background Hand injuries account for approximately 20% of emergency department visits [1]. According to the National Hospital Ambulatory Medical Care Survey, 1.5% of all emergency department visits involve hand and wrist fractures. Distal radius fractures are especially common, accounting for up to 18% of fractures in the elderly [2,3]. Because of increasing rates of osteoporosis, the incidence of distal radius fractures has been increasing [4]. Although most distal radius fractures in elderly patients are managed nonoperatively, the use of internal fixation is increasing. Internal fixation has a much higher cost than nonoperative treatment as well as increased rates of hospitalization [5]. For most patients with trauma to the hand and wrist, conventional radiographs provide sufficient diagnostic information to guide the treating physician. However, delayed diagnosis is common because distal radius and scaphoid fractures may be radiographically occult [6]. When initial radiographs are normal but there is high clinical suspicion for fracture, further imaging with additional radiographic projections, CT, or MRI is appropriate. If associated soft-tissue injury is clinically suspected, CT, CT arthrography, MRI, MR arthrography, or ultrasound (US) may be indicated [7-10]. Successful treatment of distal radius fractures requires restoration of radial length, inclination, and tilt, as well as the realignment of the articular fracture fragments [9,11]. The presence of a coronally oriented fracture line, die- punch depression, or more than three articular fracture fragments are common indications for operative reduction [8]. Operative fixation resulting in <2 mm of residual articular surface step-off is usually considered necessary to avoid long-term complications, such as osteoarthritis [9,12]. A standard 3-view radiographic examination of the hand shows most fractures and dislocations of the metacarpals and phalanges [13]. | 69418 |
acrac_69418_1 | Acute Hand and Wrist Trauma | For phalangeal injuries, some centers include a PA examination of the entire hand, whereas others limit the examination to the injured finger. An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures [15]. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Acute Hand and Wrist Trauma Most fractures of the thumb are visible on a 2-view radiographic examination, although there is a slight increase in diagnostic yield with the addition of an oblique projection [13], which can be obtained along with a PA examination of the whole hand. CT Area of Interest In patients with intra-articular fractures seen on radiography, CT shows articular fracture fragment displacement, depression, and comminution more accurately than conventional radiographs [7,9,10]. CT measurements of articular surface gap and step-off are more reproducible than radiographs [7]. The addition of 3-D surface- rendered reconstructions to the standard 2-D CT images has been shown to change operative management in up to 48% of intra-articular distal radius fractures [8]. There is no evidence to support the use of CT with intravenous (IV) contrast in the setting of acute hand and wrist trauma. MRI Area of Interest MRI is not indicated initially in this clinical setting. US Area of Interest US is not indicated initially in this clinical setting. Bone Scan Area of Interest Bone scan is not indicated in this clinical setting. Variant 2: Suspect acute hand or wrist trauma. Initial radiographs negative or equivocal. Next imaging study. | Acute Hand and Wrist Trauma. For phalangeal injuries, some centers include a PA examination of the entire hand, whereas others limit the examination to the injured finger. An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures [15]. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Acute Hand and Wrist Trauma Most fractures of the thumb are visible on a 2-view radiographic examination, although there is a slight increase in diagnostic yield with the addition of an oblique projection [13], which can be obtained along with a PA examination of the whole hand. CT Area of Interest In patients with intra-articular fractures seen on radiography, CT shows articular fracture fragment displacement, depression, and comminution more accurately than conventional radiographs [7,9,10]. CT measurements of articular surface gap and step-off are more reproducible than radiographs [7]. The addition of 3-D surface- rendered reconstructions to the standard 2-D CT images has been shown to change operative management in up to 48% of intra-articular distal radius fractures [8]. There is no evidence to support the use of CT with intravenous (IV) contrast in the setting of acute hand and wrist trauma. MRI Area of Interest MRI is not indicated initially in this clinical setting. US Area of Interest US is not indicated initially in this clinical setting. Bone Scan Area of Interest Bone scan is not indicated in this clinical setting. Variant 2: Suspect acute hand or wrist trauma. Initial radiographs negative or equivocal. Next imaging study. | 69418 |
acrac_69418_2 | Acute Hand and Wrist Trauma | Radiography Area of Interest In patients with clinical suspicion of hand or wrist fracture and negative radiographs, one option is to place the patient in a short arm cast and repeat the radiographs at 10 to 14 days [13]. The downside of this option is that it results in delay of diagnosis, which may lead to functional impairment. CT Area of Interest When the initial radiographs are equivocal, CT without IV contrast is commonly used to exclude or confirm suspected wrist fractures [18]. CT shows intra-articular extension of distal radius fractures more frequently than radiography. Three-dimensional reconstructions can be particularly helpful in preoperative planning for complex articular injuries [7,8]. CT should be used to exclude an occult fracture of the upper extremity. Unlike MRI, CT cannot evaluate for concomitant ligamentous injuries [19-21]. CT is useful in diagnosing injuries that are difficult to recognize on radiographs, such as carpometacarpal joint fracture dislocations. For metacarpal and digital fractures, CT is usually not indicated during acute injury [22]. There is no evidence to support the use of CT with IV contrast in the setting of acute hand and wrist trauma. MRI Area of Interest When initial radiographs are normal but there is high clinical suspicion for fracture, MRI without IV contrast can detect fractures of the distal radius and carpal bones [12,23-25]. One study of patients in which the radiographic findings did not explain the clinical symptoms reported that the MRI led to a change in diagnosis in 55% of patients and a change in patient management in 66% [12]. However, another study of patients with acutely injured wrists reported that the MRI did not predict the need for treatment better than the combination of physical examination and radiography [23]. More importantly, there was no difference in outcomes with MRI compared with radiography [24]. | Acute Hand and Wrist Trauma. Radiography Area of Interest In patients with clinical suspicion of hand or wrist fracture and negative radiographs, one option is to place the patient in a short arm cast and repeat the radiographs at 10 to 14 days [13]. The downside of this option is that it results in delay of diagnosis, which may lead to functional impairment. CT Area of Interest When the initial radiographs are equivocal, CT without IV contrast is commonly used to exclude or confirm suspected wrist fractures [18]. CT shows intra-articular extension of distal radius fractures more frequently than radiography. Three-dimensional reconstructions can be particularly helpful in preoperative planning for complex articular injuries [7,8]. CT should be used to exclude an occult fracture of the upper extremity. Unlike MRI, CT cannot evaluate for concomitant ligamentous injuries [19-21]. CT is useful in diagnosing injuries that are difficult to recognize on radiographs, such as carpometacarpal joint fracture dislocations. For metacarpal and digital fractures, CT is usually not indicated during acute injury [22]. There is no evidence to support the use of CT with IV contrast in the setting of acute hand and wrist trauma. MRI Area of Interest When initial radiographs are normal but there is high clinical suspicion for fracture, MRI without IV contrast can detect fractures of the distal radius and carpal bones [12,23-25]. One study of patients in which the radiographic findings did not explain the clinical symptoms reported that the MRI led to a change in diagnosis in 55% of patients and a change in patient management in 66% [12]. However, another study of patients with acutely injured wrists reported that the MRI did not predict the need for treatment better than the combination of physical examination and radiography [23]. More importantly, there was no difference in outcomes with MRI compared with radiography [24]. | 69418 |
acrac_69418_3 | Acute Hand and Wrist Trauma | Acute Hand and Wrist Trauma Like CT, MRI shows intra-articular extension of distal radius fractures more frequently than radiography. Unlike CT, MRI shows concomitant ligament injuries, including tears of the scapholunate ligament, which may affect surgical treatment [26,27]. Despite these advantages, MRI performed immediately at the time of injury has little added value for determining which patients go on to surgery [23]. MRI is especially useful in evaluating hand soft-tissues injuries, including the collateral ligaments, volar plates, tendons, and pulleys. For metacarpal and digital fractures, MRI is usually not indicated during acute injury [22]. There is no evidence to support the use of MRI with IV contrast in the setting of acute hand and wrist trauma. US Area of Interest US may have a limited utility for evaluating bone injuries. Christiansen et al [28] reported 47% sensitivity and 61% specificity of US for the detection of scaphoid fractures. They concluded that US is not suitable for the early diagnosis of scaphoid fracture. In contrast, Hauger et al [29] reported that using cortical disruption as a diagnostic criterion on US is an accurate sign for detecting occult fractures of the scaphoid waist. Further study of US for the diagnosis of occult fractures is needed. Bone Scan Area of Interest Bone scan is not indicated in this clinical setting. CT Arthrography Wrist When conventional radiographs do not show carpal malalignment, CT arthrography may be used to diagnose ligamentous tears, causing dynamic instability [32,33]. There is a growing body of literature comparing the diagnostic accuracy of MRI (at 1.5T or 3T), MR arthrography (indirect or direct at 1.5T or 3T), and CT arthrography. Overall, CT arthrography is reported to have the highest sensitivity, specificity, and accuracy. For the detection of scapholunate ligament tear, CT arthrography has sensitivity, specificity, and accuracy of nearly 100%. | Acute Hand and Wrist Trauma. Acute Hand and Wrist Trauma Like CT, MRI shows intra-articular extension of distal radius fractures more frequently than radiography. Unlike CT, MRI shows concomitant ligament injuries, including tears of the scapholunate ligament, which may affect surgical treatment [26,27]. Despite these advantages, MRI performed immediately at the time of injury has little added value for determining which patients go on to surgery [23]. MRI is especially useful in evaluating hand soft-tissues injuries, including the collateral ligaments, volar plates, tendons, and pulleys. For metacarpal and digital fractures, MRI is usually not indicated during acute injury [22]. There is no evidence to support the use of MRI with IV contrast in the setting of acute hand and wrist trauma. US Area of Interest US may have a limited utility for evaluating bone injuries. Christiansen et al [28] reported 47% sensitivity and 61% specificity of US for the detection of scaphoid fractures. They concluded that US is not suitable for the early diagnosis of scaphoid fracture. In contrast, Hauger et al [29] reported that using cortical disruption as a diagnostic criterion on US is an accurate sign for detecting occult fractures of the scaphoid waist. Further study of US for the diagnosis of occult fractures is needed. Bone Scan Area of Interest Bone scan is not indicated in this clinical setting. CT Arthrography Wrist When conventional radiographs do not show carpal malalignment, CT arthrography may be used to diagnose ligamentous tears, causing dynamic instability [32,33]. There is a growing body of literature comparing the diagnostic accuracy of MRI (at 1.5T or 3T), MR arthrography (indirect or direct at 1.5T or 3T), and CT arthrography. Overall, CT arthrography is reported to have the highest sensitivity, specificity, and accuracy. For the detection of scapholunate ligament tear, CT arthrography has sensitivity, specificity, and accuracy of nearly 100%. | 69418 |
acrac_69418_4 | Acute Hand and Wrist Trauma | For the detection of lunotriquetral ligament tear, CT arthrography has approximately 100% sensitivity, 80% specificity, and 90% accuracy. Compared with arthroscopy, CT arthrography has 80% to 100% sensitivity for scapholunate and lunotriquetral ligament tears [33-35]. Compared to MR arthrography, CT arthrography detects partial ligament tears more accurately, detects articular cartilage defects more accurately, and has greater interobserver agreement [33]. Both CT arthrography and MR arthrography have a very high accuracy for diagnosing tears of the scapholunate ligament and lunotriquetral ligament; both are more accurate than conventional MRI [36]. The accuracy of CT arthrography for extrinsic ligament injuries is unknown [37]. CT Wrist CT is not indicated in this clinical setting. MRI Wrist When conventional radiographs do not show carpal malalignment, MRI is commonly used to diagnose ligamentous tears. In the clinical setting of dynamic instability, MRI or MR arthrography may be performed. Modern MR techniques using 3T systems, dedicated wrist coils, and 3-D isovolumetric sequences offer fast imaging times with high spatial and contrast resolution [36,38]. In general, 1.5T MRI has moderate sensitivity for the detection of scapholunate ligament tears and poor sensitivity for lunotriquetral ligament tears [35]. A meta-analysis of 11 studies reported sensitivities and specificities of 70% and 90% for detection of scapholunate ligament tears and 31% and 89% for detection of lunotriquetral ligament tears, respectively [39]. Sensitivity of 3T MRI is slightly better than 1.5T for the diagnosis of interosseous ligament tears. Reported sensitivities range from 65% to 89% for scapholunate ligament tears and 60% to 82% for lunotriquetral ligament Acute Hand and Wrist Trauma tears [36,40-42]. Some investigators consider the diagnostic accuracy of 3T MRI and MR arthrography to be comparable [38]. The accuracy of MRI for extrinsic ligament assessment is unknown [37]. | Acute Hand and Wrist Trauma. For the detection of lunotriquetral ligament tear, CT arthrography has approximately 100% sensitivity, 80% specificity, and 90% accuracy. Compared with arthroscopy, CT arthrography has 80% to 100% sensitivity for scapholunate and lunotriquetral ligament tears [33-35]. Compared to MR arthrography, CT arthrography detects partial ligament tears more accurately, detects articular cartilage defects more accurately, and has greater interobserver agreement [33]. Both CT arthrography and MR arthrography have a very high accuracy for diagnosing tears of the scapholunate ligament and lunotriquetral ligament; both are more accurate than conventional MRI [36]. The accuracy of CT arthrography for extrinsic ligament injuries is unknown [37]. CT Wrist CT is not indicated in this clinical setting. MRI Wrist When conventional radiographs do not show carpal malalignment, MRI is commonly used to diagnose ligamentous tears. In the clinical setting of dynamic instability, MRI or MR arthrography may be performed. Modern MR techniques using 3T systems, dedicated wrist coils, and 3-D isovolumetric sequences offer fast imaging times with high spatial and contrast resolution [36,38]. In general, 1.5T MRI has moderate sensitivity for the detection of scapholunate ligament tears and poor sensitivity for lunotriquetral ligament tears [35]. A meta-analysis of 11 studies reported sensitivities and specificities of 70% and 90% for detection of scapholunate ligament tears and 31% and 89% for detection of lunotriquetral ligament tears, respectively [39]. Sensitivity of 3T MRI is slightly better than 1.5T for the diagnosis of interosseous ligament tears. Reported sensitivities range from 65% to 89% for scapholunate ligament tears and 60% to 82% for lunotriquetral ligament Acute Hand and Wrist Trauma tears [36,40-42]. Some investigators consider the diagnostic accuracy of 3T MRI and MR arthrography to be comparable [38]. The accuracy of MRI for extrinsic ligament assessment is unknown [37]. | 69418 |
acrac_69418_5 | Acute Hand and Wrist Trauma | Extensor carpi ulnaris tendinopathy, tenosynovitis, and tendon rupture can be evaluated with MRI or US [43]. However, dynamic instability may be missed on MRI, unless sequences are performed in pronation and supination [44]. MR Arthrography Wrist At 1.5T, MR arthrography has greater sensitivity compared with conventional MRI [45,46]. Both MRI and MR arthrography have poor to moderate sensitivity for partial ligament tears [47,48]. When only complete tears are considered, MRI and MR arthrography may be equivalent [33]. The accuracy of MR arthrography for extrinsic ligament assessment is unknown [37]. For tears of the dorsal band of the scapholunate ligament, US sensitivity varies from 46% to 100% and specificity from 92% to 100% [50-52]. For the dorsal band of the lunotriquetral ligament, US sensitivity ranges from 25% to 50% and specificity from 90% to 100% [52,53]. US visualization of lunotriquetral ligament (particularly the structurally important volar band) is limited [49]. US can show dynamic subluxation of the extensor carpi ulnaris tendon during forced supination [44]. Bone Scan Wrist Bone scan is not indicated in this clinical setting. Variant 4: Initial radiographs showing distal radioulnar joint or carpal malalignment in the absence of fracture. Next imaging study. CT Wrist CT is the modality of choice for evaluating distal radioulnar joint stability [54]. The CT protocol should include imaging of both wrists in maximal pronation, neutral position, and maximal supination. CT examination with coronal, sagittal, and 3-D reformed images help demonstrate the extent of injury and help in treatment planning, particularly in cases of chronic perilunate dislocation [55]. CT Arthrography Wrist Distal radioulnar joint instability and traumatic triangular fibrocartilage injuries can be evaluated with CT arthrography [56,57]. | Acute Hand and Wrist Trauma. Extensor carpi ulnaris tendinopathy, tenosynovitis, and tendon rupture can be evaluated with MRI or US [43]. However, dynamic instability may be missed on MRI, unless sequences are performed in pronation and supination [44]. MR Arthrography Wrist At 1.5T, MR arthrography has greater sensitivity compared with conventional MRI [45,46]. Both MRI and MR arthrography have poor to moderate sensitivity for partial ligament tears [47,48]. When only complete tears are considered, MRI and MR arthrography may be equivalent [33]. The accuracy of MR arthrography for extrinsic ligament assessment is unknown [37]. For tears of the dorsal band of the scapholunate ligament, US sensitivity varies from 46% to 100% and specificity from 92% to 100% [50-52]. For the dorsal band of the lunotriquetral ligament, US sensitivity ranges from 25% to 50% and specificity from 90% to 100% [52,53]. US visualization of lunotriquetral ligament (particularly the structurally important volar band) is limited [49]. US can show dynamic subluxation of the extensor carpi ulnaris tendon during forced supination [44]. Bone Scan Wrist Bone scan is not indicated in this clinical setting. Variant 4: Initial radiographs showing distal radioulnar joint or carpal malalignment in the absence of fracture. Next imaging study. CT Wrist CT is the modality of choice for evaluating distal radioulnar joint stability [54]. The CT protocol should include imaging of both wrists in maximal pronation, neutral position, and maximal supination. CT examination with coronal, sagittal, and 3-D reformed images help demonstrate the extent of injury and help in treatment planning, particularly in cases of chronic perilunate dislocation [55]. CT Arthrography Wrist Distal radioulnar joint instability and traumatic triangular fibrocartilage injuries can be evaluated with CT arthrography [56,57]. | 69418 |
acrac_69418_6 | Acute Hand and Wrist Trauma | MRI Wrist Distal radioulnar joint instability and traumatic triangular fibrocartilage injuries are usually associated with fluid in the distal radioulnar joint, which aids in the evaluation of the triangular fibrocartilage components on conventional MRI. MR Arthrography Wrist MR arthrography increases the diagnostic accuracy for proximal lamina (foveal) triangular fibrocartilage tears [56,57]. US Wrist US is not indicated in this clinical setting. Bone Scan Wrist Bone scan is not indicated in this clinical setting. Variant 5: Acute hand fracture on radiographs. Suspect hand tendon or ligament trauma. Next imaging study. CT Hand CT has limited use for the diagnosis of soft-tissue injuries of the hand. Acute Hand and Wrist Trauma MRI Hand MRI is ideal for evaluating tendon injuries and helping with surgical planning [58,59]. MRI is commonly used for the diagnosis of Stener lesions of the thumb [60] and the diagnosis of pulley system injuries [61]. Hergan et al [62] reported a 100% sensitivity and specificity for assessment of thumb ulnar collateral ligament tears. Spaeth et al [63] reported a sensitivity of 100% and specificity of 94% for detection of displaced ulnar collateral ligament tears in 16 cadaveric specimens. US Hand A Stener lesion occurs when the aponeurosis of the adductor pollicis muscle becomes interposed between the ruptured ulnar collateral ligament of the thumb and its site of insertion at the base of the proximal phalanx. This lesion can be identified by absence of ulnar collateral ligament and the presence of a hypoechoic mass proximal to the apex of the metacarpal tubercle [64]. Dynamic examination shows the relationship of the aponeurosis to the retracted ligament stump [65]. US allows for diagnosis of pulley system injuries [66,67]. Bone Scan Hand Bone scan is not indicated in this clinical setting. Variant 6: Initial radiographs showing metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joint malalignment in the absence of fracture. | Acute Hand and Wrist Trauma. MRI Wrist Distal radioulnar joint instability and traumatic triangular fibrocartilage injuries are usually associated with fluid in the distal radioulnar joint, which aids in the evaluation of the triangular fibrocartilage components on conventional MRI. MR Arthrography Wrist MR arthrography increases the diagnostic accuracy for proximal lamina (foveal) triangular fibrocartilage tears [56,57]. US Wrist US is not indicated in this clinical setting. Bone Scan Wrist Bone scan is not indicated in this clinical setting. Variant 5: Acute hand fracture on radiographs. Suspect hand tendon or ligament trauma. Next imaging study. CT Hand CT has limited use for the diagnosis of soft-tissue injuries of the hand. Acute Hand and Wrist Trauma MRI Hand MRI is ideal for evaluating tendon injuries and helping with surgical planning [58,59]. MRI is commonly used for the diagnosis of Stener lesions of the thumb [60] and the diagnosis of pulley system injuries [61]. Hergan et al [62] reported a 100% sensitivity and specificity for assessment of thumb ulnar collateral ligament tears. Spaeth et al [63] reported a sensitivity of 100% and specificity of 94% for detection of displaced ulnar collateral ligament tears in 16 cadaveric specimens. US Hand A Stener lesion occurs when the aponeurosis of the adductor pollicis muscle becomes interposed between the ruptured ulnar collateral ligament of the thumb and its site of insertion at the base of the proximal phalanx. This lesion can be identified by absence of ulnar collateral ligament and the presence of a hypoechoic mass proximal to the apex of the metacarpal tubercle [64]. Dynamic examination shows the relationship of the aponeurosis to the retracted ligament stump [65]. US allows for diagnosis of pulley system injuries [66,67]. Bone Scan Hand Bone scan is not indicated in this clinical setting. Variant 6: Initial radiographs showing metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joint malalignment in the absence of fracture. | 69418 |
acrac_69418_7 | Acute Hand and Wrist Trauma | Next imaging study. CT Hand CT has limited use for the diagnosis of soft-tissue injuries of the fingers. MRI Hand MRI is ideal for evaluating tendon injuries and helping with surgical planning [58]. MRI may be used to assess capsule and collateral ligament injuries of the proximal interphalangeal and metacarpophalangeal joints [68]. MRI allows for the assessment of pulley system lesions [66,67]. MRI can accurately depict the pulley system, particularly the A2 and A4 pulleys, with lower sensitivity for A3 and A5 pulleys [70]. Hauger et al [70] reported direct identification of A2 and A4 pulleys in 12 of 12 cases (100%) and direct diagnosis of an abnormal A2 pulley in 100% and A4 pulley in 91% of 33 cases. For volar plate injuries, MRI may be used to diagnose tears that do not involve the underlying bone [71]. This is important because untreated lesions can result in contractures or joint laxity [72]. MRI is especially useful for detection of ulnar collateral ligament and radial collateral ligament injuries. Pfirrmann et al [74] reported a sensitivity of 67% and a specificity of 91% for collateral ligament injuries of the lesser metacarpophalangeal joints. With MR arthrography, sensitivity and specificity increased to 75% and 98%, respectively [74]. US Hand Dynamic US allows direct visualization of subluxation/dislocation of the extensor tendon while the patient flexes the metacarpophalangeal joint [16,75]. US helps evaluate injured flexor tendons and, in cases of completely lacerated tendons, helps identify the location of the proximal tendon stump [76]. Acute Hand and Wrist Trauma US allows for assessment of pulley system injuries [66,67], particularly the A2 and A4 pulleys, with lower sensitivity for A3 and A5 pulleys [70]. Bone Scan Hand Bone scan is not indicated in this clinical setting. Variant 7: Suspect penetrating trauma with a foreign body in the soft tissues in the hand or wrist. Initial radiographs are negative. Next imaging study. | Acute Hand and Wrist Trauma. Next imaging study. CT Hand CT has limited use for the diagnosis of soft-tissue injuries of the fingers. MRI Hand MRI is ideal for evaluating tendon injuries and helping with surgical planning [58]. MRI may be used to assess capsule and collateral ligament injuries of the proximal interphalangeal and metacarpophalangeal joints [68]. MRI allows for the assessment of pulley system lesions [66,67]. MRI can accurately depict the pulley system, particularly the A2 and A4 pulleys, with lower sensitivity for A3 and A5 pulleys [70]. Hauger et al [70] reported direct identification of A2 and A4 pulleys in 12 of 12 cases (100%) and direct diagnosis of an abnormal A2 pulley in 100% and A4 pulley in 91% of 33 cases. For volar plate injuries, MRI may be used to diagnose tears that do not involve the underlying bone [71]. This is important because untreated lesions can result in contractures or joint laxity [72]. MRI is especially useful for detection of ulnar collateral ligament and radial collateral ligament injuries. Pfirrmann et al [74] reported a sensitivity of 67% and a specificity of 91% for collateral ligament injuries of the lesser metacarpophalangeal joints. With MR arthrography, sensitivity and specificity increased to 75% and 98%, respectively [74]. US Hand Dynamic US allows direct visualization of subluxation/dislocation of the extensor tendon while the patient flexes the metacarpophalangeal joint [16,75]. US helps evaluate injured flexor tendons and, in cases of completely lacerated tendons, helps identify the location of the proximal tendon stump [76]. Acute Hand and Wrist Trauma US allows for assessment of pulley system injuries [66,67], particularly the A2 and A4 pulleys, with lower sensitivity for A3 and A5 pulleys [70]. Bone Scan Hand Bone scan is not indicated in this clinical setting. Variant 7: Suspect penetrating trauma with a foreign body in the soft tissues in the hand or wrist. Initial radiographs are negative. Next imaging study. | 69418 |
acrac_3099053_0 | Chylothorax Treatment Planning | Introduction/Background Chyle is primarily formed in the intestines and is composed of proteins, lipids, electrolytes, and lymphocytes. A chylous pleural effusion, or chylothorax, is a highly morbid condition defined by the presence of chyle within the pleural respiratory compromise, immunosuppression, malnutrition, and even death [1-3]. A review of the etiology, diagnosis, and management of chylothorax is presented in addition to an evaluation of relevant imaging studies. Etiology Chylothoraces can be categorized etiologically as traumatic or nontraumatic. Collectively, the incidence of chylothorax is approximately 1 per 6000 admissions [1]. Historically, nontraumatic etiologies accounted for up to 72% of cases. Most recently, the largest study reports that traumatic etiologies account for 54% of cases [1,4-7]. The discrepancy may reflect the growth in thoracic oncologic resections or specific referral patterns. Diagnosis Chylothorax most commonly presents with dyspnea, although chest pain, fever, and fatigue may also occur. Chyle is odorless, alkaline, sterile, and milky in appearance, although the appearance may vary based on the nutritional status of the patient. Increasing fatty intake increases the volume and can change the color of the fluid and has been described for the diagnosis of a chyle leak. The hallmark of chylous effusion is the presence of chylomicrons in the fluid. Objective diagnostic criteria include a pleural fluid triglyceride level >110 mg/dL and a ratio of pleural fluid to serum triglyceride level of >1.0. A ratio of pleural fluid to serum cholesterol level of <1.0 distinguishes chylothorax from cholesterol pleural effusions, which may present similarly [2,3]. Management The diagnosis is confirmed by draining the fluid for studies; this is also palliative. After replacing fluid and protein losses, a decision about conservative versus invasive therapies can be made. | Chylothorax Treatment Planning. Introduction/Background Chyle is primarily formed in the intestines and is composed of proteins, lipids, electrolytes, and lymphocytes. A chylous pleural effusion, or chylothorax, is a highly morbid condition defined by the presence of chyle within the pleural respiratory compromise, immunosuppression, malnutrition, and even death [1-3]. A review of the etiology, diagnosis, and management of chylothorax is presented in addition to an evaluation of relevant imaging studies. Etiology Chylothoraces can be categorized etiologically as traumatic or nontraumatic. Collectively, the incidence of chylothorax is approximately 1 per 6000 admissions [1]. Historically, nontraumatic etiologies accounted for up to 72% of cases. Most recently, the largest study reports that traumatic etiologies account for 54% of cases [1,4-7]. The discrepancy may reflect the growth in thoracic oncologic resections or specific referral patterns. Diagnosis Chylothorax most commonly presents with dyspnea, although chest pain, fever, and fatigue may also occur. Chyle is odorless, alkaline, sterile, and milky in appearance, although the appearance may vary based on the nutritional status of the patient. Increasing fatty intake increases the volume and can change the color of the fluid and has been described for the diagnosis of a chyle leak. The hallmark of chylous effusion is the presence of chylomicrons in the fluid. Objective diagnostic criteria include a pleural fluid triglyceride level >110 mg/dL and a ratio of pleural fluid to serum triglyceride level of >1.0. A ratio of pleural fluid to serum cholesterol level of <1.0 distinguishes chylothorax from cholesterol pleural effusions, which may present similarly [2,3]. Management The diagnosis is confirmed by draining the fluid for studies; this is also palliative. After replacing fluid and protein losses, a decision about conservative versus invasive therapies can be made. | 3099053 |
acrac_3099053_1 | Chylothorax Treatment Planning | If the chylothorax reaccumulates, treatment is guided by daily outputs, with higher outputs warranting a more aggressive approach [2,4,8-11]. Conservative measures include management of the underlying disease, thoracentesis, and dietary modifications such as total parenteral nutrition or a nonfat diet to reduce production of chyle and consequently flow through the thoracic duct. Adjunctive therapy may include somatostatin, etilefrine, or nitric oxide, with the underlying etiology determining the efficacy, although the evidence remains scarce. The success of conservative therapy approaches 50% in nonmalignant etiologies but is only minimally beneficial in neoplastic etiologies [2,10,11]. Exact criteria for the implementation of invasive treatment are not well defined, but several authors advocate its use if conservative treatment has not resolved the chylothorax after 2 weeks, in higher-output chylothoraces, and in underlying neoplastic etiologies. Invasive treatments include surgical thoracic duct ligation, pleurodesis, and thoracic duct embolization (TDE) [2,4,8-11]. Less commonly, tunneled drains or pleural shunt procedures are performed, although prolonged drainage is not recommended as a long-term option because of increased risk of complications [12,13]. Although the technical success of direct surgical ligation is high, these debilitated patients 1Principal Author and Panel Vice-Chair (Vascular Imaging), University of Michigan Health System, Ann Arbor, Michigan. 2Research Author, University of Michigan, Ann Arbor, Michigan. 3Panel Chair (Interventional Radiology), Cleveland Clinic Foundation, Cleveland, Ohio. 4Yuma Regional Medical Center, Yuma, Arizona. 5Massachusetts General Hospital, Boston, Massachusetts. 6Beth Israel Deaconess Medical Center, Boston, Massachusetts, Society of Thoracic Surgeons. 7Vanderbilt University Medical Center, Nashville, Tennessee, American College of Chest Physicians. 8University of Nebraska Medical Center, Omaha, Nebraska. | Chylothorax Treatment Planning. If the chylothorax reaccumulates, treatment is guided by daily outputs, with higher outputs warranting a more aggressive approach [2,4,8-11]. Conservative measures include management of the underlying disease, thoracentesis, and dietary modifications such as total parenteral nutrition or a nonfat diet to reduce production of chyle and consequently flow through the thoracic duct. Adjunctive therapy may include somatostatin, etilefrine, or nitric oxide, with the underlying etiology determining the efficacy, although the evidence remains scarce. The success of conservative therapy approaches 50% in nonmalignant etiologies but is only minimally beneficial in neoplastic etiologies [2,10,11]. Exact criteria for the implementation of invasive treatment are not well defined, but several authors advocate its use if conservative treatment has not resolved the chylothorax after 2 weeks, in higher-output chylothoraces, and in underlying neoplastic etiologies. Invasive treatments include surgical thoracic duct ligation, pleurodesis, and thoracic duct embolization (TDE) [2,4,8-11]. Less commonly, tunneled drains or pleural shunt procedures are performed, although prolonged drainage is not recommended as a long-term option because of increased risk of complications [12,13]. Although the technical success of direct surgical ligation is high, these debilitated patients 1Principal Author and Panel Vice-Chair (Vascular Imaging), University of Michigan Health System, Ann Arbor, Michigan. 2Research Author, University of Michigan, Ann Arbor, Michigan. 3Panel Chair (Interventional Radiology), Cleveland Clinic Foundation, Cleveland, Ohio. 4Yuma Regional Medical Center, Yuma, Arizona. 5Massachusetts General Hospital, Boston, Massachusetts. 6Beth Israel Deaconess Medical Center, Boston, Massachusetts, Society of Thoracic Surgeons. 7Vanderbilt University Medical Center, Nashville, Tennessee, American College of Chest Physicians. 8University of Nebraska Medical Center, Omaha, Nebraska. | 3099053 |
acrac_3099053_2 | Chylothorax Treatment Planning | 9University of California San Diego, San Diego, California. 10University of Texas Southwestern Medical Center, Dallas, Texas. 11Specialty Chair (Interventional Radiology), University of Chicago Hospital, Chicago, Illinois. 12Panel Chair (Vascular Imaging), UT Southwestern Medical Center, Dallas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Chylothorax Treatment Planning are at increased risk for postoperative adhesions, infection, and poor wound healing. Reported postoperative mortality rates for patients who have failed conservative management range from 4.5% to as high as 50% [2,4,9,10]. TDE is a percutaneous alternative to thoracic duct ligation. TDE allows for direct embolization (Type I) or needle disruption of the thoracic duct (Type II). Whereas the former directly treats the focus of injury, the latter is purported to create a controlled leak and inflammatory reaction in the retroperitoneum, which collateralizes and diverts flow from the thoracic duct. Over several successive publications, Cope et al [14,15] defined the technique and reported its feasibility. The initial series of 42 patients by Cope and Kaiser [16] revealed effective percutaneous treatment in >70% of cases. In 109 patients with traumatic thoracic duct leak, Itkin et al [5] reported 90% clinical resolution postembolization and 72% clinical resolution of the chyle leak with thoracic duct disruption. A subsequent report by Nadolski and Itkin [6] reported that TDE for nontraumatic chylous effusions in 34 patients was primarily successful if there was thoracic duct occlusion and extravasation. | Chylothorax Treatment Planning. 9University of California San Diego, San Diego, California. 10University of Texas Southwestern Medical Center, Dallas, Texas. 11Specialty Chair (Interventional Radiology), University of Chicago Hospital, Chicago, Illinois. 12Panel Chair (Vascular Imaging), UT Southwestern Medical Center, Dallas. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Chylothorax Treatment Planning are at increased risk for postoperative adhesions, infection, and poor wound healing. Reported postoperative mortality rates for patients who have failed conservative management range from 4.5% to as high as 50% [2,4,9,10]. TDE is a percutaneous alternative to thoracic duct ligation. TDE allows for direct embolization (Type I) or needle disruption of the thoracic duct (Type II). Whereas the former directly treats the focus of injury, the latter is purported to create a controlled leak and inflammatory reaction in the retroperitoneum, which collateralizes and diverts flow from the thoracic duct. Over several successive publications, Cope et al [14,15] defined the technique and reported its feasibility. The initial series of 42 patients by Cope and Kaiser [16] revealed effective percutaneous treatment in >70% of cases. In 109 patients with traumatic thoracic duct leak, Itkin et al [5] reported 90% clinical resolution postembolization and 72% clinical resolution of the chyle leak with thoracic duct disruption. A subsequent report by Nadolski and Itkin [6] reported that TDE for nontraumatic chylous effusions in 34 patients was primarily successful if there was thoracic duct occlusion and extravasation. | 3099053 |
acrac_3099053_3 | Chylothorax Treatment Planning | Pamarthi et al [7] reported 85% technical success and 64% clinical success in 105 patients with all-cause chylous leaks. Additional series have yielded similar results. Collectively, TDE has higher clinical success treating traumatic compared with nontraumatic chyle leaks and with TDE compared with thoracic duct disruption [8,9,11,17]. Overall, acute complications associated with TDE are minor and generally self-limited and are estimated at 2% to 6% [5-7]. Long-term complications may be seen in up to 14% of patients and may include leg swelling, abdominal swelling, or chronic diarrhea [18]. Overview of Imaging Modalities Different imaging studies serve different purposes in the evaluation and treatment of chylothorax. Chest radiography Chest radiographs are routine examinations to evaluate dyspnea, particularly in postoperative scenarios and in patients who require intensive care. Radiographs can reliably detect pleural effusions or alternative diagnoses and monitor the position of support lines and tubes [19]. Although there is a high sensitivity for pleural effusions, this technique cannot reliably characterize the type of effusion. Ultrasound Ultrasound (US) is sensitive for the detection of pleural fluid but cannot definitively discriminate between the types of pleural effusion [20]. US is now commonly used to help guide thoracentesis. Similarly, US can be used to facilitate intranodal lymphangiography, which is becoming a more accepted technique. Beyond facilitating these procedures, the role of US is limited with regard to the evaluation and management of chylothorax [21]. Conventional lymphangiography Lymphangiography has historically been used to opacify lymphatic vessels, detect lymph nodes and metastatic lesions, and evaluate lymphatic flow. | Chylothorax Treatment Planning. Pamarthi et al [7] reported 85% technical success and 64% clinical success in 105 patients with all-cause chylous leaks. Additional series have yielded similar results. Collectively, TDE has higher clinical success treating traumatic compared with nontraumatic chyle leaks and with TDE compared with thoracic duct disruption [8,9,11,17]. Overall, acute complications associated with TDE are minor and generally self-limited and are estimated at 2% to 6% [5-7]. Long-term complications may be seen in up to 14% of patients and may include leg swelling, abdominal swelling, or chronic diarrhea [18]. Overview of Imaging Modalities Different imaging studies serve different purposes in the evaluation and treatment of chylothorax. Chest radiography Chest radiographs are routine examinations to evaluate dyspnea, particularly in postoperative scenarios and in patients who require intensive care. Radiographs can reliably detect pleural effusions or alternative diagnoses and monitor the position of support lines and tubes [19]. Although there is a high sensitivity for pleural effusions, this technique cannot reliably characterize the type of effusion. Ultrasound Ultrasound (US) is sensitive for the detection of pleural fluid but cannot definitively discriminate between the types of pleural effusion [20]. US is now commonly used to help guide thoracentesis. Similarly, US can be used to facilitate intranodal lymphangiography, which is becoming a more accepted technique. Beyond facilitating these procedures, the role of US is limited with regard to the evaluation and management of chylothorax [21]. Conventional lymphangiography Lymphangiography has historically been used to opacify lymphatic vessels, detect lymph nodes and metastatic lesions, and evaluate lymphatic flow. | 3099053 |
acrac_3099053_4 | Chylothorax Treatment Planning | Technological improvements in alternative diagnostic modalities led to an abandonment of this technique for oncologic purposes because it was technically challenging and time intensive, provided less information, and was more invasive. Although proficiency and training in the performance of lymphangiograms decreased, the utility of lymphangiography to demonstrate lymphatic leak became an established indication [8,9,14,22,23]. Traditionally, lymphangiography is performed from a pedal approach with the patient in a supine position. In this technique, a dye such as methylene blue that stains the lymphatics is injected into the web spaces between the toes. After the lymphatic vessel fills with the dye, the tissue overlying the lymphatic vessel is incised vertically, the lymphatic vessel is carefully skeletonized, and a 30-gauge lymphangiography needle is used to access the vessel. After securing the lymphatic access, 6 to 8 mL of ethiodized oil is instilled at a rate of 4 to 10 mL/h. Serial spot radiographs from the foot to the chest are acquired approximately every 10 to 15 minutes to follow the progression of the ethiodized oil as it ascends [22,24-27]. More recently, an interest in nodal lymphangiography has developed [21,28]. In this alternative approach, an inguinal lymph node is targeted with a 25- to 26-gauge spinal needle under US guidance. The needle is positioned between the hilum and cortex of a lymph node. Hand injection of ethiodized oil at a rate of 1 mL per 5 to 7 minutes is then initiated for a total volume of 6 to 10 mL. Serial spot radiographs of the pelvis, abdomen, and thorax are then acquired to follow the progression of ethiodized oil [21,25,28-30]. Intranodal lymphangiography appears to decrease procedure time, is less technically challenging, and decreases the risk of wound infection when compared to pedal lymphangiography [21,28]. | Chylothorax Treatment Planning. Technological improvements in alternative diagnostic modalities led to an abandonment of this technique for oncologic purposes because it was technically challenging and time intensive, provided less information, and was more invasive. Although proficiency and training in the performance of lymphangiograms decreased, the utility of lymphangiography to demonstrate lymphatic leak became an established indication [8,9,14,22,23]. Traditionally, lymphangiography is performed from a pedal approach with the patient in a supine position. In this technique, a dye such as methylene blue that stains the lymphatics is injected into the web spaces between the toes. After the lymphatic vessel fills with the dye, the tissue overlying the lymphatic vessel is incised vertically, the lymphatic vessel is carefully skeletonized, and a 30-gauge lymphangiography needle is used to access the vessel. After securing the lymphatic access, 6 to 8 mL of ethiodized oil is instilled at a rate of 4 to 10 mL/h. Serial spot radiographs from the foot to the chest are acquired approximately every 10 to 15 minutes to follow the progression of the ethiodized oil as it ascends [22,24-27]. More recently, an interest in nodal lymphangiography has developed [21,28]. In this alternative approach, an inguinal lymph node is targeted with a 25- to 26-gauge spinal needle under US guidance. The needle is positioned between the hilum and cortex of a lymph node. Hand injection of ethiodized oil at a rate of 1 mL per 5 to 7 minutes is then initiated for a total volume of 6 to 10 mL. Serial spot radiographs of the pelvis, abdomen, and thorax are then acquired to follow the progression of ethiodized oil [21,25,28-30]. Intranodal lymphangiography appears to decrease procedure time, is less technically challenging, and decreases the risk of wound infection when compared to pedal lymphangiography [21,28]. | 3099053 |
acrac_3099053_5 | Chylothorax Treatment Planning | Chylothorax Treatment Planning Lymphangiography is able to define the site of the leak, diagnose alternative lymphatic vessel diseases, and prevent unnecessary procedures. Several authors have documented the therapeutic benefit of lymphangiography to occlude the site of leakage in 37% to 70% of patients without additional procedures [24-30]. Moreover, as detailed earlier, lymphangiography is intrinsic to the performance of TDE and guides the transabdominal access to the cisterna chyli and thoracic duct [14-16]. Magnetic resonance imaging chest and abdomen Visualization of the cisterna chyli, thoracic duct, and tributary lymphatic vessels with magnetic resonance imaging (MRI) was described in healthy volunteers as early as 1999 [34]. Initial MR lymphangiography technique involved unenhanced thin-collimated axial and coronal sequences similar to magnetic resonance cholangiopancreatography. Further refinements of sequences, particularly heavily T2-weighted sequences with and without and fat suppression, combined with 3-D techniques, maximum-intensity projections, and higher magnetic fields, increased the reliability and quality of MR lymphangiography [35-39]. Morphological features of the cisterna chyli and thoracic duct can be noted with identification of these structures in over 90% of preoperative patients, potentially providing valuable information and decreasing their risk of lymphatic leak [40- 43]. The vast majority of studies are performed with unenhanced techniques, although delayed-phase cisterna chyli enhancement has been noted [44]. Respiratory gating and further technical refinements have the potential to better elucidate minor lymphatic vessels and lymphatic vessels in antidependent areas, which may not be seen through conventional lymphangiography. Recent studies are beginning to document the feasibility of using gadolinium- based contrast material injection within groin lymph nodes or in the web spaces between toes. | Chylothorax Treatment Planning. Chylothorax Treatment Planning Lymphangiography is able to define the site of the leak, diagnose alternative lymphatic vessel diseases, and prevent unnecessary procedures. Several authors have documented the therapeutic benefit of lymphangiography to occlude the site of leakage in 37% to 70% of patients without additional procedures [24-30]. Moreover, as detailed earlier, lymphangiography is intrinsic to the performance of TDE and guides the transabdominal access to the cisterna chyli and thoracic duct [14-16]. Magnetic resonance imaging chest and abdomen Visualization of the cisterna chyli, thoracic duct, and tributary lymphatic vessels with magnetic resonance imaging (MRI) was described in healthy volunteers as early as 1999 [34]. Initial MR lymphangiography technique involved unenhanced thin-collimated axial and coronal sequences similar to magnetic resonance cholangiopancreatography. Further refinements of sequences, particularly heavily T2-weighted sequences with and without and fat suppression, combined with 3-D techniques, maximum-intensity projections, and higher magnetic fields, increased the reliability and quality of MR lymphangiography [35-39]. Morphological features of the cisterna chyli and thoracic duct can be noted with identification of these structures in over 90% of preoperative patients, potentially providing valuable information and decreasing their risk of lymphatic leak [40- 43]. The vast majority of studies are performed with unenhanced techniques, although delayed-phase cisterna chyli enhancement has been noted [44]. Respiratory gating and further technical refinements have the potential to better elucidate minor lymphatic vessels and lymphatic vessels in antidependent areas, which may not be seen through conventional lymphangiography. Recent studies are beginning to document the feasibility of using gadolinium- based contrast material injection within groin lymph nodes or in the web spaces between toes. | 3099053 |
acrac_3099053_6 | Chylothorax Treatment Planning | Following the contrast material injection, patients are imaged with MRI. High image quality of lymph nodes, central lymphatics, and flow patterns within the lymphatics has been described, but these are preliminary research experiences and are not widely available [45,46]. Computed tomography chest and abdomen Older studies noted that noncontrast computed tomography (CT) visualizes the cisterna chyli in 1.7% of cases and could differentiate this from adjacent anatomy by its low attenuation, continuity with the thoracic duct, and tubular nature [47]. At least some portion of the thoracic duct was visualized in 55% of patients in a different series [48]. Although MRI more reliably visualized more segments of the thoracic duct than CT, the addition of CT increased the number of visualized segments [36]. More recent studies with 1-mm collimation and multiplanar reformation were able to identify the thoracic duct and cisterna chyli in nearly 100% of CT scans with normal anatomy [49]. Older reports using a combination of lymphangiography and CT did not find any additional value of CT in diagnosing the lymphatic injury, although in a more recent series, a combination of CT and unilateral pedal lymphangiography was able to identify the cause and locate the leak in 75% of idiopathic chylothoraces after failure of thoracic duct ligation [30]. Moreover, in this series of 24 patients, the lack of thoracic duct leakage was managed with nonoperative therapy with higher success rates [30]. No evidence is present to suggest a role for intravenous contrast material. When the underlying etiology of chylothorax is unknown or nontraumatic, the speed, sensitivity, and specificity of CT imaging can narrow the broader differential diagnosis. Discussion of the Imaging Modalities by Variant Variant 1: Chylothorax treatment planning: traumatic etiology. Traumatic chylothoraces are a result of direct injury to thoracic lymphatics. | Chylothorax Treatment Planning. Following the contrast material injection, patients are imaged with MRI. High image quality of lymph nodes, central lymphatics, and flow patterns within the lymphatics has been described, but these are preliminary research experiences and are not widely available [45,46]. Computed tomography chest and abdomen Older studies noted that noncontrast computed tomography (CT) visualizes the cisterna chyli in 1.7% of cases and could differentiate this from adjacent anatomy by its low attenuation, continuity with the thoracic duct, and tubular nature [47]. At least some portion of the thoracic duct was visualized in 55% of patients in a different series [48]. Although MRI more reliably visualized more segments of the thoracic duct than CT, the addition of CT increased the number of visualized segments [36]. More recent studies with 1-mm collimation and multiplanar reformation were able to identify the thoracic duct and cisterna chyli in nearly 100% of CT scans with normal anatomy [49]. Older reports using a combination of lymphangiography and CT did not find any additional value of CT in diagnosing the lymphatic injury, although in a more recent series, a combination of CT and unilateral pedal lymphangiography was able to identify the cause and locate the leak in 75% of idiopathic chylothoraces after failure of thoracic duct ligation [30]. Moreover, in this series of 24 patients, the lack of thoracic duct leakage was managed with nonoperative therapy with higher success rates [30]. No evidence is present to suggest a role for intravenous contrast material. When the underlying etiology of chylothorax is unknown or nontraumatic, the speed, sensitivity, and specificity of CT imaging can narrow the broader differential diagnosis. Discussion of the Imaging Modalities by Variant Variant 1: Chylothorax treatment planning: traumatic etiology. Traumatic chylothoraces are a result of direct injury to thoracic lymphatics. | 3099053 |
acrac_3099053_7 | Chylothorax Treatment Planning | Iatrogenic traumatic chylothorax complicates up to 4% of esophageal resections [1,2,4-7]. Lung cancer resections, cardiovascular surgeries, and Chylothorax Treatment Planning spinal surgeries can also be complicated by chylothorax, although at a lesser rate. Noniatrogenic causes of traumatic chylothorax include penetrating trauma, fracture-dislocation of the spine, and hyperflexion injuries [1,6,7]. Generally, the causative etiology is known in the traumatic setting. Sampling the pleural effusion confirms the diagnosis of chylothorax. Imaging a patient with a known traumatic chylothorax serves only to confirm the diagnosis and assist in therapeutic planning. Chest radiography In the setting of a traumatic injury to the thoracic duct, most commonly postoperative or mechanical trauma, chest radiographs can confirm the presence of pleural fluid and lateralize the process and are routinely acquired in the daily evaluation of supportive lines and tubes [19]. Ultrasound US can be helpful in the guidance of thoracentesis and intranodal injection during lymphangiography [21]. Otherwise, US has little, if any, diagnostic role in the setting of a known traumatic chylothorax. Conventional lymphangiography Conventional lymphangiography is the gold standard for visualization of lymph nodes, lymphatic vessels, cisterna chyli, the thoracic duct, and sites of injury [14,22,23]. Lymphangiography alone has been shown to be therapeutic in a small percentage of patients, irrespective of attempts at TDE or disruption [24-27]. When performed as a prelude to TDE, the combination is particularly effective in treating traumatic chylothorax, with technical and clinical success rates approaching 90% [5-9,11]. Nuclear lymphoscintigraphy Although nuclear lymphoscintigraphy may be able to confirm a lymphatic leak and identify the site, little evidence is present to support its routine use [31-33]. | Chylothorax Treatment Planning. Iatrogenic traumatic chylothorax complicates up to 4% of esophageal resections [1,2,4-7]. Lung cancer resections, cardiovascular surgeries, and Chylothorax Treatment Planning spinal surgeries can also be complicated by chylothorax, although at a lesser rate. Noniatrogenic causes of traumatic chylothorax include penetrating trauma, fracture-dislocation of the spine, and hyperflexion injuries [1,6,7]. Generally, the causative etiology is known in the traumatic setting. Sampling the pleural effusion confirms the diagnosis of chylothorax. Imaging a patient with a known traumatic chylothorax serves only to confirm the diagnosis and assist in therapeutic planning. Chest radiography In the setting of a traumatic injury to the thoracic duct, most commonly postoperative or mechanical trauma, chest radiographs can confirm the presence of pleural fluid and lateralize the process and are routinely acquired in the daily evaluation of supportive lines and tubes [19]. Ultrasound US can be helpful in the guidance of thoracentesis and intranodal injection during lymphangiography [21]. Otherwise, US has little, if any, diagnostic role in the setting of a known traumatic chylothorax. Conventional lymphangiography Conventional lymphangiography is the gold standard for visualization of lymph nodes, lymphatic vessels, cisterna chyli, the thoracic duct, and sites of injury [14,22,23]. Lymphangiography alone has been shown to be therapeutic in a small percentage of patients, irrespective of attempts at TDE or disruption [24-27]. When performed as a prelude to TDE, the combination is particularly effective in treating traumatic chylothorax, with technical and clinical success rates approaching 90% [5-9,11]. Nuclear lymphoscintigraphy Although nuclear lymphoscintigraphy may be able to confirm a lymphatic leak and identify the site, little evidence is present to support its routine use [31-33]. | 3099053 |
acrac_3099053_8 | Chylothorax Treatment Planning | Moreover, this adds little to the clinical care of a patient as the traumatic etiology is usually known and any information gained would be redundant if conventional lymphangiography was performed as part of TDE. Magnetic resonance imaging chest and abdomen The diagnostic benefit of MRI is negated in the setting of traumatic chylothoraces. However, the ability of MRI to map the lymphatic system can be of benefit in select cases where identifying the cisterna chyli and/or thoracic duct is difficult or conventional lymphangiography is unsuccessful [40-43]. Computed tomography chest and abdomen CT imaging is able to visualize portions of lymphatic system but provides less anatomic detail than MRI [36,47,48]. If the etiology is known, CT of the chest and abdomen, with or without intravenous contrast material, has little value in that it does not help guide therapy directed at chylothorax in most cases. Variant 2: Chylothorax treatment planning: nontraumatic or unknown etiology. Nontraumatic chylothorax accounts for approximately 46% of chylothoraces and can be subcategorized as resulting from malignancy, as occurs in 18% of all chylothoraces, or nonmalignant etiologies, which account for 28% of all chylothoraces [1,2,6,7]. Of the malignant etiologies, lymphoma is the leading cause, accounting for 75% of all malignant chylothoraces. Nonmalignant, nontraumatic chylothorax has been described in lymphangioleiomyomatosis, sarcoidosis, cirrhosis, heart failure, nephrotic syndrome, venous thrombosis, filariasis, venolymphatic malformations, and a variety of other congenital, idiopathic, and systemic diseases. Approximately 9% of all chylous effusions are idiopathic [1,2,6,7]. Imaging a patient with either a nontraumatic chylothorax or a chylothorax of unknown etiology serves to narrow the differential diagnosis, further characterize the underlying cause and its severity, and assist in treatment planning. | Chylothorax Treatment Planning. Moreover, this adds little to the clinical care of a patient as the traumatic etiology is usually known and any information gained would be redundant if conventional lymphangiography was performed as part of TDE. Magnetic resonance imaging chest and abdomen The diagnostic benefit of MRI is negated in the setting of traumatic chylothoraces. However, the ability of MRI to map the lymphatic system can be of benefit in select cases where identifying the cisterna chyli and/or thoracic duct is difficult or conventional lymphangiography is unsuccessful [40-43]. Computed tomography chest and abdomen CT imaging is able to visualize portions of lymphatic system but provides less anatomic detail than MRI [36,47,48]. If the etiology is known, CT of the chest and abdomen, with or without intravenous contrast material, has little value in that it does not help guide therapy directed at chylothorax in most cases. Variant 2: Chylothorax treatment planning: nontraumatic or unknown etiology. Nontraumatic chylothorax accounts for approximately 46% of chylothoraces and can be subcategorized as resulting from malignancy, as occurs in 18% of all chylothoraces, or nonmalignant etiologies, which account for 28% of all chylothoraces [1,2,6,7]. Of the malignant etiologies, lymphoma is the leading cause, accounting for 75% of all malignant chylothoraces. Nonmalignant, nontraumatic chylothorax has been described in lymphangioleiomyomatosis, sarcoidosis, cirrhosis, heart failure, nephrotic syndrome, venous thrombosis, filariasis, venolymphatic malformations, and a variety of other congenital, idiopathic, and systemic diseases. Approximately 9% of all chylous effusions are idiopathic [1,2,6,7]. Imaging a patient with either a nontraumatic chylothorax or a chylothorax of unknown etiology serves to narrow the differential diagnosis, further characterize the underlying cause and its severity, and assist in treatment planning. | 3099053 |
acrac_3099053_9 | Chylothorax Treatment Planning | Most patients with nontraumatic chylothoraces or chylothoraces of unknown etiologies present with acute respiratory illness (ARI), which consists of 1 or more of the following: cough, sputum production, chest pain, or dyspnea (with or without fever). The evaluation of ARI has been addressed by the American College of Radiology (ACR), and the imaging evaluation includes chest radiography and chest CT [50,51]. The consistent finding of chylothorax on initial imaging is the presence of a pleural effusion, which is a common medical problem with more than 50 recognized causes [52]. Pleural fluid studies are necessary for definitive diagnosis and to narrow the cause etiology of chylothorax. Ultrasound US reliably detects pleural fluid but cannot definitively discriminate between the types of pleural effusion and provides minimal additional information to narrow the differential diagnosis [20]. US can be helpful in the guidance of thoracentesis and intranodal injection during lymphangiography [21]. Conventional lymphangiography Conventional lymphangiography is the gold standard for visualization of lymph nodes, lymphatic vessels, cisterna chyli, and the thoracic duct and for detection of lymphatic leakage [14,22,23]. In a nontraumatic or idiopathic chylothorax, conventional lymphangiography may help diagnose lymphatic vessel diseases and anatomic abnormalities and prevent unnecessary procedures. However, compared with traumatic chylothorax and particularly in the setting of a systemic disease, conventional lymphangiography does not always elucidate the underlying etiology. Additionally, TDE is less clinically effective in a nontraumatic chylothorax unless thoracic duct occlusion or extravasation is present [6]. Nuclear lymphoscintigraphy Nuclear lymphoscintigraphy has only a few reports that suggest it may be able to localize the site of chylous leak, particularly if used with 3-D single-photon emission CT/CT techniques [31-33]. | Chylothorax Treatment Planning. Most patients with nontraumatic chylothoraces or chylothoraces of unknown etiologies present with acute respiratory illness (ARI), which consists of 1 or more of the following: cough, sputum production, chest pain, or dyspnea (with or without fever). The evaluation of ARI has been addressed by the American College of Radiology (ACR), and the imaging evaluation includes chest radiography and chest CT [50,51]. The consistent finding of chylothorax on initial imaging is the presence of a pleural effusion, which is a common medical problem with more than 50 recognized causes [52]. Pleural fluid studies are necessary for definitive diagnosis and to narrow the cause etiology of chylothorax. Ultrasound US reliably detects pleural fluid but cannot definitively discriminate between the types of pleural effusion and provides minimal additional information to narrow the differential diagnosis [20]. US can be helpful in the guidance of thoracentesis and intranodal injection during lymphangiography [21]. Conventional lymphangiography Conventional lymphangiography is the gold standard for visualization of lymph nodes, lymphatic vessels, cisterna chyli, and the thoracic duct and for detection of lymphatic leakage [14,22,23]. In a nontraumatic or idiopathic chylothorax, conventional lymphangiography may help diagnose lymphatic vessel diseases and anatomic abnormalities and prevent unnecessary procedures. However, compared with traumatic chylothorax and particularly in the setting of a systemic disease, conventional lymphangiography does not always elucidate the underlying etiology. Additionally, TDE is less clinically effective in a nontraumatic chylothorax unless thoracic duct occlusion or extravasation is present [6]. Nuclear lymphoscintigraphy Nuclear lymphoscintigraphy has only a few reports that suggest it may be able to localize the site of chylous leak, particularly if used with 3-D single-photon emission CT/CT techniques [31-33]. | 3099053 |
acrac_3158179_0 | Workup of Pleural Effusion or Pleural Disease | Introduction/Background Under normal circumstances, approximately 0.1 to 0.2 mL/kg body weight of pleural fluid resides in the pleural space [1]. Abnormal accumulation of pleural fluid is the most common clinical manifestation of pleural disease [2], typically caused by increased pulmonary capillary pressure, increased pleural membrane permeability, decreased oncotic pressure, or lymphatic obstruction [3]. Pleural effusions are categorized as transudative or exudative [4], with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura [5]. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders [6], emphasizing the importance of prompt diagnosis to aid in patient management [7]. In general, physical examination findings have a lower positive likelihood ratio for detection of pleural effusions [8], supporting the use of imaging to aid in identification of clinically significant pleural effusions. When imaging pleural effusions, chest radiographs can typically detect >75 mL on the lateral view and >175 mL on the frontal view [9]. Thoracic ultrasound (US) can detect >20 mL of pleural fluid [10]. Chest CT can detect >10 mL of pleural fluid, and is considered the reference standard for imaging [11]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. | Workup of Pleural Effusion or Pleural Disease. Introduction/Background Under normal circumstances, approximately 0.1 to 0.2 mL/kg body weight of pleural fluid resides in the pleural space [1]. Abnormal accumulation of pleural fluid is the most common clinical manifestation of pleural disease [2], typically caused by increased pulmonary capillary pressure, increased pleural membrane permeability, decreased oncotic pressure, or lymphatic obstruction [3]. Pleural effusions are categorized as transudative or exudative [4], with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura [5]. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders [6], emphasizing the importance of prompt diagnosis to aid in patient management [7]. In general, physical examination findings have a lower positive likelihood ratio for detection of pleural effusions [8], supporting the use of imaging to aid in identification of clinically significant pleural effusions. When imaging pleural effusions, chest radiographs can typically detect >75 mL on the lateral view and >175 mL on the frontal view [9]. Thoracic ultrasound (US) can detect >20 mL of pleural fluid [10]. Chest CT can detect >10 mL of pleural fluid, and is considered the reference standard for imaging [11]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. | 3158179 |
acrac_3158179_1 | Workup of Pleural Effusion or Pleural Disease | OR The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Workup of Pleural Effusion or Pleural Disease Discussion of Procedures by Variant Variant 1: Recent pneumonia with suspected parapneumonic effusion or empyema. Initial imaging. CT Chest With IV Contrast Current American Association for Thoracic Surgery consensus guidelines recommend CT chest with intravenous (IV) contrast in cases of suspected parapneumonic effusion (class IIa) [13]. A recent meta-analysis reported 5 chest CT findings most commonly associated with the diagnosis of empyema: pleural enhancement (sensitivity 84%, 95% confidence interval [CI], 62%-94%; specificity 83%, 95% CI, 75%-89%), pleural thickening (sensitivity 68%, 95% CI, 56%-77%; specificity 87%, 95% CI, 80%-92%), loculation (sensitivity 52%, 95% CI, 44%-59%; specificity 89%; 95% CI, 82%-94%), extrapleural fat proliferation (sensitivity 53%, 95% CI, 47%-60%; specificity 91%, 95% CI, 82%-96%), and increased attenuation of the extrapleural fat (sensitivity 39%, 95% CI, 32%-48%; specificity 97%, 95% CI, 94%-98%) [14]. Of note, these pooled sensitivities and specificities include CT chest with IV contrast or CT chest without IV contrast. Pleural enhancement has the highest area under curve for the diagnosis of empyema (0.86) and for distinguishing between simple parapneumonic effusion and empyema (0.83) [14]. | Workup of Pleural Effusion or Pleural Disease. OR The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Workup of Pleural Effusion or Pleural Disease Discussion of Procedures by Variant Variant 1: Recent pneumonia with suspected parapneumonic effusion or empyema. Initial imaging. CT Chest With IV Contrast Current American Association for Thoracic Surgery consensus guidelines recommend CT chest with intravenous (IV) contrast in cases of suspected parapneumonic effusion (class IIa) [13]. A recent meta-analysis reported 5 chest CT findings most commonly associated with the diagnosis of empyema: pleural enhancement (sensitivity 84%, 95% confidence interval [CI], 62%-94%; specificity 83%, 95% CI, 75%-89%), pleural thickening (sensitivity 68%, 95% CI, 56%-77%; specificity 87%, 95% CI, 80%-92%), loculation (sensitivity 52%, 95% CI, 44%-59%; specificity 89%; 95% CI, 82%-94%), extrapleural fat proliferation (sensitivity 53%, 95% CI, 47%-60%; specificity 91%, 95% CI, 82%-96%), and increased attenuation of the extrapleural fat (sensitivity 39%, 95% CI, 32%-48%; specificity 97%, 95% CI, 94%-98%) [14]. Of note, these pooled sensitivities and specificities include CT chest with IV contrast or CT chest without IV contrast. Pleural enhancement has the highest area under curve for the diagnosis of empyema (0.86) and for distinguishing between simple parapneumonic effusion and empyema (0.83) [14]. | 3158179 |
acrac_3158179_2 | Workup of Pleural Effusion or Pleural Disease | In a secondary analysis of the Multi-centre Intra-pleural Sepsis Trial (MIST) 2 trial of patients with laboratory proven pleural infection, the combination of parietal pleural enhancement and pleural thickening was seen in 98.7% of patients (95% CI, 92.8%-99.8%) on pleural-phase contrast-enhanced CT [15]. The presence of pleural enhancement with pleural gas/microbubbles [16] or larger pleural effusion size [17] also boosts the accuracy for identifying parapneumonic effusions requiring thoracentesis [16,17]. Parapneumonic effusions <2.5 cm in anteroposterior (AP) dimension can often be managed without thoracentesis [18]. From a technical perspective, acquiring the CT scan 60 seconds after the IV contrast bolus optimizes visualization of the pleura [19,20]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. If a noncontrast CT is obtained, 4 out of 5 chest CT findings most commonly associated with the diagnosis of empyema in a recent meta-analysis may be ascertained without IV contrast: pleural thickening (sensitivity 68%, 95% CI, 56%-77%; specificity 87%; 95% CI, 80%-92%), loculation (sensitivity 52%, 95% CI, 44%-59%; specificity 89%; 95% CI, 82%-94%), fat thickening (sensitivity 53%, 95% CI, 47%-60%; specificity 91%; 95% CI, 82%-96%), and fat stranding (sensitivity 39%, 95% CI, 32%- 48%; specificity 97%; 95% CI, 94%-98%) [14]. Of note, these pooled sensitivities and specificities include CT chest with IV contrast or CT chest without IV contrast. | Workup of Pleural Effusion or Pleural Disease. In a secondary analysis of the Multi-centre Intra-pleural Sepsis Trial (MIST) 2 trial of patients with laboratory proven pleural infection, the combination of parietal pleural enhancement and pleural thickening was seen in 98.7% of patients (95% CI, 92.8%-99.8%) on pleural-phase contrast-enhanced CT [15]. The presence of pleural enhancement with pleural gas/microbubbles [16] or larger pleural effusion size [17] also boosts the accuracy for identifying parapneumonic effusions requiring thoracentesis [16,17]. Parapneumonic effusions <2.5 cm in anteroposterior (AP) dimension can often be managed without thoracentesis [18]. From a technical perspective, acquiring the CT scan 60 seconds after the IV contrast bolus optimizes visualization of the pleura [19,20]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. If a noncontrast CT is obtained, 4 out of 5 chest CT findings most commonly associated with the diagnosis of empyema in a recent meta-analysis may be ascertained without IV contrast: pleural thickening (sensitivity 68%, 95% CI, 56%-77%; specificity 87%; 95% CI, 80%-92%), loculation (sensitivity 52%, 95% CI, 44%-59%; specificity 89%; 95% CI, 82%-94%), fat thickening (sensitivity 53%, 95% CI, 47%-60%; specificity 91%; 95% CI, 82%-96%), and fat stranding (sensitivity 39%, 95% CI, 32%- 48%; specificity 97%; 95% CI, 94%-98%) [14]. Of note, these pooled sensitivities and specificities include CT chest with IV contrast or CT chest without IV contrast. | 3158179 |
acrac_3158179_3 | Workup of Pleural Effusion or Pleural Disease | Gas in the pleural space is another specific marker for complicated parapneumonic effusion, with specificities ranging from 81% (95% CI, 73%-87%) to 96% (95% CI, 86%-99%) [16,17]. Parapneumonic effusions <2.5 cm in AP dimension can often be managed without thoracentesis [18]. CTA Chest With IV Contrast There is no relevant literature to support the use of CTA chest with IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. Note that CTA often employs contrast timing that is earlier than 60 seconds and therefore does not allow sufficient time for pleural enhancement. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema in adults. In case reports, MRI chest without and with IV contrast has been used as an adjunctive modality for the diagnosis of empyema necessitans [21]. In pediatric patients, limited data suggests MRI is noninferior to CT chest with IV contrast for the diagnosis of empyema [22-24]. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. In small studies, diffusion weighted imaging [25] Workup of Pleural Effusion or Pleural Disease and T1 mapping [26] have shown promise in distinguishing exudative from transudative pleural effusions without contrast material. Radiography Chest Consensus recommendations endorse chest radiography as the initial imaging modality for patients with recent pneumonia and suspected pleural effusion [27,28]; however, there are limited empiric data to support these recommendations. Posteroanterior (PA) and lateral radiographs have a significantly greater sensitivity for the detection of parapneumonic effusions than single-view AP radiographs. | Workup of Pleural Effusion or Pleural Disease. Gas in the pleural space is another specific marker for complicated parapneumonic effusion, with specificities ranging from 81% (95% CI, 73%-87%) to 96% (95% CI, 86%-99%) [16,17]. Parapneumonic effusions <2.5 cm in AP dimension can often be managed without thoracentesis [18]. CTA Chest With IV Contrast There is no relevant literature to support the use of CTA chest with IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. Note that CTA often employs contrast timing that is earlier than 60 seconds and therefore does not allow sufficient time for pleural enhancement. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema in adults. In case reports, MRI chest without and with IV contrast has been used as an adjunctive modality for the diagnosis of empyema necessitans [21]. In pediatric patients, limited data suggests MRI is noninferior to CT chest with IV contrast for the diagnosis of empyema [22-24]. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast in the initial imaging of recent pneumonia with suspected parapneumonic effusion or empyema. In small studies, diffusion weighted imaging [25] Workup of Pleural Effusion or Pleural Disease and T1 mapping [26] have shown promise in distinguishing exudative from transudative pleural effusions without contrast material. Radiography Chest Consensus recommendations endorse chest radiography as the initial imaging modality for patients with recent pneumonia and suspected pleural effusion [27,28]; however, there are limited empiric data to support these recommendations. Posteroanterior (PA) and lateral radiographs have a significantly greater sensitivity for the detection of parapneumonic effusions than single-view AP radiographs. | 3158179 |
acrac_3158179_4 | Workup of Pleural Effusion or Pleural Disease | In a retrospective analysis of patients from the Community-Acquired Pneumonia Organization international cohort study, PA and lateral radiographs had a sensitivity of 83.9% versus 67.3% for AP radiographs when using CT as the reference standard [29]. Single-view PA, single lateral view, or single-view AP radiographs have been shown to have statistically equivalent sensitivities for detection of parapneumonic effusions [30], with most missed parapneumonic effusions occurring in patients with coexistent lower lobe consolidation [30]. The specificity of chest radiography for the detection of complicated parapneumonic effusions, defined as those requiring thoracentesis, is modest. For example, in a retrospective study of 66 patients undergoing thoracentesis for parapneumonic effusions, chest radiography had a specificity of 60% for the detection of complicated parapneumonic effusions [31]. US Chest Identification of a pleural effusion for possible US-guided thoracentesis is currently the primary reason for chest US [32]. Current American Association for Thoracic Surgery consensus guidelines recommend thoracic US for the diagnostic evaluation of pleural space infection (class I), typically occurring in patients with prior imaging documenting the presence of a pleural effusion [13]. US findings of septations [33,34], increased echogenicity of the pleural effusion [31,35], pleural thickening [36], and microbubbles [37] are associated with parapneumonic effusion/empyema. A retrospective study of 66 patients with suspected parapneumonic effusion found that US chest had a significantly higher specificity (90%, 95% CI, 76.3%-97.2%) and a nonsignificant difference in sensitivity (69.2%, 95% CI, 48.2%-87.7%) compared with CT chest for the diagnosis of complicated parapneumonic effusion [31]. A retrospective comparison of US chest and CT chest in pediatric patients found similar accuracy for the detection of parapneumonic effusion [38]. | Workup of Pleural Effusion or Pleural Disease. In a retrospective analysis of patients from the Community-Acquired Pneumonia Organization international cohort study, PA and lateral radiographs had a sensitivity of 83.9% versus 67.3% for AP radiographs when using CT as the reference standard [29]. Single-view PA, single lateral view, or single-view AP radiographs have been shown to have statistically equivalent sensitivities for detection of parapneumonic effusions [30], with most missed parapneumonic effusions occurring in patients with coexistent lower lobe consolidation [30]. The specificity of chest radiography for the detection of complicated parapneumonic effusions, defined as those requiring thoracentesis, is modest. For example, in a retrospective study of 66 patients undergoing thoracentesis for parapneumonic effusions, chest radiography had a specificity of 60% for the detection of complicated parapneumonic effusions [31]. US Chest Identification of a pleural effusion for possible US-guided thoracentesis is currently the primary reason for chest US [32]. Current American Association for Thoracic Surgery consensus guidelines recommend thoracic US for the diagnostic evaluation of pleural space infection (class I), typically occurring in patients with prior imaging documenting the presence of a pleural effusion [13]. US findings of septations [33,34], increased echogenicity of the pleural effusion [31,35], pleural thickening [36], and microbubbles [37] are associated with parapneumonic effusion/empyema. A retrospective study of 66 patients with suspected parapneumonic effusion found that US chest had a significantly higher specificity (90%, 95% CI, 76.3%-97.2%) and a nonsignificant difference in sensitivity (69.2%, 95% CI, 48.2%-87.7%) compared with CT chest for the diagnosis of complicated parapneumonic effusion [31]. A retrospective comparison of US chest and CT chest in pediatric patients found similar accuracy for the detection of parapneumonic effusion [38]. | 3158179 |
acrac_3158179_5 | Workup of Pleural Effusion or Pleural Disease | CT Chest With IV Contrast CT chest with IV contrast or CTA chest with IV contrast is regarded as the reference standard for the noninvasive assessment of thoracic injury in patients with chest trauma, regardless of severity, and a clinical indication for imaging [42]. The goal of CT chest with IV contrast is to identify hemothorax and contrast extravasation. The incidence of pleural effusion on chest CT in minor blunt trauma is unknown; however, in a retrospective study of 2,440 multiple trauma patients undergoing whole body CT with IV contrast, 2.2% had an incidental pleural effusion [43]. In a secondary analysis of the prospective observational NEXUS Chest and NEXUS Chest CT studies of patients with major or minor blunt trauma, 1.8% of patients had a hemothorax on CTA chest with IV contrast [44]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging of recent minor blunt trauma with suspected pleural effusion. CTA Chest With IV Contrast CTA chest with IV contrast or CT chest with IV contrast is regarded as the reference standard for the noninvasive assessment of thoracic injury in patients with chest trauma and a clinical indication for imaging [42]. The goal of Workup of Pleural Effusion or Pleural Disease CTA chest with IV contrast is to identify hemothorax and contrast extravasation. The incidence of pleural effusion on chest CT in minor blunt trauma is unknown; however, in a retrospective study of 2,440 multiple trauma patients undergoing whole body CT with IV contrast, 2.2% had an incidental pleural effusion [43]. In a secondary analysis of the prospective observational NEXUS Chest and NEXUS Chest CT studies of patients with major or minor blunt trauma, 1.8% of patients had a hemothorax on CTA chest with IV contrast [44]. | Workup of Pleural Effusion or Pleural Disease. CT Chest With IV Contrast CT chest with IV contrast or CTA chest with IV contrast is regarded as the reference standard for the noninvasive assessment of thoracic injury in patients with chest trauma, regardless of severity, and a clinical indication for imaging [42]. The goal of CT chest with IV contrast is to identify hemothorax and contrast extravasation. The incidence of pleural effusion on chest CT in minor blunt trauma is unknown; however, in a retrospective study of 2,440 multiple trauma patients undergoing whole body CT with IV contrast, 2.2% had an incidental pleural effusion [43]. In a secondary analysis of the prospective observational NEXUS Chest and NEXUS Chest CT studies of patients with major or minor blunt trauma, 1.8% of patients had a hemothorax on CTA chest with IV contrast [44]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging of recent minor blunt trauma with suspected pleural effusion. CTA Chest With IV Contrast CTA chest with IV contrast or CT chest with IV contrast is regarded as the reference standard for the noninvasive assessment of thoracic injury in patients with chest trauma and a clinical indication for imaging [42]. The goal of Workup of Pleural Effusion or Pleural Disease CTA chest with IV contrast is to identify hemothorax and contrast extravasation. The incidence of pleural effusion on chest CT in minor blunt trauma is unknown; however, in a retrospective study of 2,440 multiple trauma patients undergoing whole body CT with IV contrast, 2.2% had an incidental pleural effusion [43]. In a secondary analysis of the prospective observational NEXUS Chest and NEXUS Chest CT studies of patients with major or minor blunt trauma, 1.8% of patients had a hemothorax on CTA chest with IV contrast [44]. | 3158179 |
acrac_3158179_6 | Workup of Pleural Effusion or Pleural Disease | Image-Guided Aspiration Chest There is no relevant literature to support the use of image-guided aspiration chest in the initial imaging of recent minor blunt trauma with suspected pleural effusion. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast in the initial imaging of recent minor blunt trauma with suspected pleural effusion. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast in the initial imaging of recent minor blunt trauma with suspected pleural effusion. Radiography Chest Chest radiography is considered a first-line imaging test for patients with chest trauma and a clinical indication for imaging [46]. In the prospective NEXUS Chest CT trial, blunt trauma patients without an abnormal chest radiograph and 6 clinical criteria could avoid an unnecessary chest CT (sensitivity 99.2%; 95% CI, 95.4%-100%, specificity 20.8%; 95% CI, 19.2%-22.4%) [47]. A meta-analysis of the pooled sensitivity and specificity of chest radiographs for the detection of hemothorax in patients with chest trauma was 54% (95% CI, 33%-75%) and 99% (95% CI, 94%-100%), respectively, when using chest CT as the reference standard [48]. A study of 24 patients using only PA radiographs found a similar sensitivity of 62.5% and specificity of 100% for the detection of pleural effusions in patients with chest trauma [49]. In 2 prospective series of patients with minor blunt thoracic trauma and an initial normal chest radiograph, 7.4% to 11.8% had a pleural effusion on follow-up radiography within 2 weeks, clinically ascribed as a delayed hemothorax [39,40]. A delayed hemothorax on chest radiographs after minor blunt thoracic trauma was significantly more likely in patients with at least 1 fracture between the third and ninth ribs [50]. US Chest The sensitivity and specificity of chest US for only minor blunt trauma has not been reported. | Workup of Pleural Effusion or Pleural Disease. Image-Guided Aspiration Chest There is no relevant literature to support the use of image-guided aspiration chest in the initial imaging of recent minor blunt trauma with suspected pleural effusion. MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast in the initial imaging of recent minor blunt trauma with suspected pleural effusion. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast in the initial imaging of recent minor blunt trauma with suspected pleural effusion. Radiography Chest Chest radiography is considered a first-line imaging test for patients with chest trauma and a clinical indication for imaging [46]. In the prospective NEXUS Chest CT trial, blunt trauma patients without an abnormal chest radiograph and 6 clinical criteria could avoid an unnecessary chest CT (sensitivity 99.2%; 95% CI, 95.4%-100%, specificity 20.8%; 95% CI, 19.2%-22.4%) [47]. A meta-analysis of the pooled sensitivity and specificity of chest radiographs for the detection of hemothorax in patients with chest trauma was 54% (95% CI, 33%-75%) and 99% (95% CI, 94%-100%), respectively, when using chest CT as the reference standard [48]. A study of 24 patients using only PA radiographs found a similar sensitivity of 62.5% and specificity of 100% for the detection of pleural effusions in patients with chest trauma [49]. In 2 prospective series of patients with minor blunt thoracic trauma and an initial normal chest radiograph, 7.4% to 11.8% had a pleural effusion on follow-up radiography within 2 weeks, clinically ascribed as a delayed hemothorax [39,40]. A delayed hemothorax on chest radiographs after minor blunt thoracic trauma was significantly more likely in patients with at least 1 fracture between the third and ninth ribs [50]. US Chest The sensitivity and specificity of chest US for only minor blunt trauma has not been reported. | 3158179 |
acrac_3158179_7 | Workup of Pleural Effusion or Pleural Disease | Identification of a hemothorax for possible US-guided thoracentesis is the primary reason for chest US [32]. A recent meta-analysis reported chest US had a 60% sensitivity (95% CI, 31%-86%) and a 98% specificity (95% CI, 94%-99%) for traumatic hemothorax [51]. Variant 3: Dyspnea, cough, or chest pain with suspected pleural effusion, noninfectious. Initial imaging. CT Chest With IV Contrast In patients with suspected malignant pleural effusion or suspected unilateral pleural effusion with an increased pretest probability of malignancy, CT chest with IV contrast is recommended [52,53], although this is not limited to patients with dyspnea, cough, or chest pain. Acquiring the CT scan 60 seconds after the contrast bolus improves visualization of pleural abnormalities associated with malignancy [19]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. Heart failure, liver failure, and renal failure are common noninfectious causes of pleural effusion, and these patients may present with dyspnea, cough, or chest pain and undergo CT chest without IV contrast as part of their diagnostic workup [54,55]. CTA Chest With IV Contrast In patients with dyspnea, cough, or chest pain and suspected noninfectious pleural effusion, CTA chest with IV contrast is typically performed when there is clinical concern for pulmonary embolism [56] or aortopathy [57]. Pleural effusions in these patients are usually small and not associated with adverse clinical outcomes [57,58]. | Workup of Pleural Effusion or Pleural Disease. Identification of a hemothorax for possible US-guided thoracentesis is the primary reason for chest US [32]. A recent meta-analysis reported chest US had a 60% sensitivity (95% CI, 31%-86%) and a 98% specificity (95% CI, 94%-99%) for traumatic hemothorax [51]. Variant 3: Dyspnea, cough, or chest pain with suspected pleural effusion, noninfectious. Initial imaging. CT Chest With IV Contrast In patients with suspected malignant pleural effusion or suspected unilateral pleural effusion with an increased pretest probability of malignancy, CT chest with IV contrast is recommended [52,53], although this is not limited to patients with dyspnea, cough, or chest pain. Acquiring the CT scan 60 seconds after the contrast bolus improves visualization of pleural abnormalities associated with malignancy [19]. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. Heart failure, liver failure, and renal failure are common noninfectious causes of pleural effusion, and these patients may present with dyspnea, cough, or chest pain and undergo CT chest without IV contrast as part of their diagnostic workup [54,55]. CTA Chest With IV Contrast In patients with dyspnea, cough, or chest pain and suspected noninfectious pleural effusion, CTA chest with IV contrast is typically performed when there is clinical concern for pulmonary embolism [56] or aortopathy [57]. Pleural effusions in these patients are usually small and not associated with adverse clinical outcomes [57,58]. | 3158179 |
acrac_3158179_8 | Workup of Pleural Effusion or Pleural Disease | Workup of Pleural Effusion or Pleural Disease MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. Incidental pleural effusions have been reported in a minority of patients undergoing MRI with contrast for dyspnea, cough, or chest pain. For example, 6.6% (34/514) of patients had a moderate or large pleural effusion on contrast-enhanced MRA ordered for pulmonary embolism evaluation [59], and 4.3% (17/399) patients had a pleural effusion on stress cardiac MRI for possible acute coronary syndrome [60]. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. Radiography Chest Consensus recommendations endorse chest radiography as the initial imaging modality for patients with suspected noninfectious pleural effusion [7,61]; however, there are limited empiric data to support these recommendations. US Chest Identification of a pleural effusion for possible US-guided thoracentesis is currently the primary reason for chest US [32]. Chest US is increasingly used as part of the diagnostic pathway for patients in the emergency department [62] and in the intensive care setting [63]. A recent meta-analysis found that chest US had a pooled sensitivity of 91% (95% CI, 83%-96%) and specificity of 92% (95% CI, 82%-97%) using CT as the reference standard for identification of pleural effusion in patients in the intensive care unit [63]. Adding chest US to the conventional diagnostic pathway has been shown to reduce the time to final diagnosis in the emergency department in patients with infectious and noninfectious causes of dyspnea [64]. Variant 4: Pleural effusion incidentally detected on incomplete thoracic imaging study. Next imaging study. | Workup of Pleural Effusion or Pleural Disease. Workup of Pleural Effusion or Pleural Disease MRI Chest Without and With IV Contrast There is no relevant literature to support the use of MRI chest without and with IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. Incidental pleural effusions have been reported in a minority of patients undergoing MRI with contrast for dyspnea, cough, or chest pain. For example, 6.6% (34/514) of patients had a moderate or large pleural effusion on contrast-enhanced MRA ordered for pulmonary embolism evaluation [59], and 4.3% (17/399) patients had a pleural effusion on stress cardiac MRI for possible acute coronary syndrome [60]. MRI Chest Without IV Contrast There is no relevant literature to support the use of MRI chest without IV contrast in the initial imaging of dyspnea, cough, or chest pain with suspected noninfectious pleural effusion. Radiography Chest Consensus recommendations endorse chest radiography as the initial imaging modality for patients with suspected noninfectious pleural effusion [7,61]; however, there are limited empiric data to support these recommendations. US Chest Identification of a pleural effusion for possible US-guided thoracentesis is currently the primary reason for chest US [32]. Chest US is increasingly used as part of the diagnostic pathway for patients in the emergency department [62] and in the intensive care setting [63]. A recent meta-analysis found that chest US had a pooled sensitivity of 91% (95% CI, 83%-96%) and specificity of 92% (95% CI, 82%-97%) using CT as the reference standard for identification of pleural effusion in patients in the intensive care unit [63]. Adding chest US to the conventional diagnostic pathway has been shown to reduce the time to final diagnosis in the emergency department in patients with infectious and noninfectious causes of dyspnea [64]. Variant 4: Pleural effusion incidentally detected on incomplete thoracic imaging study. Next imaging study. | 3158179 |
acrac_3158179_9 | Workup of Pleural Effusion or Pleural Disease | The frequency of an incidental pleural effusion detected on an incomplete thoracic imaging study including neck, spine, and abdomen varies based on the indication and type of imaging modality, in the range of 1% to 5% [65-71]. The clinical significance of these incidental pleural effusions is variable. In a retrospective study of patients undergoing run-off CTA, 4.2% (9/214) had an incidental pleural effusion, leading to the diagnosis of pneumonia in 22% (2/9) and optimization of heart failure therapy in 44% (4/9) [72]. However, in a study of 352 patients undergoing MRA of the abdomen, pelvis, and lower extremities, 2.9% had an incidental pleural effusion, and no patients required follow-up diagnostic testing or change in therapy. CT Chest With IV Contrast There is no relevant literature to support the use of CT chest with IV contrast as the next imaging study following a pleural effusion incidentally detected on prior abdominal imaging. The recommendation for a follow-up CT chest with IV contrast should be based on clinical assessment (eg, clinical suspicion of malignancy). CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast as the next imaging study following a pleural effusion incidentally detected on prior abdominal imaging. The recommendation for a follow- up CT chest without and with IV contrast should be based on clinical assessment. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast as the next imaging study following a pleural effusion incidentally detected on prior abdominal imaging. The recommendation for a follow-up CT chest without IV contrast should be based on clinical assessment (eg, clinical suspicion of malignancy). | Workup of Pleural Effusion or Pleural Disease. The frequency of an incidental pleural effusion detected on an incomplete thoracic imaging study including neck, spine, and abdomen varies based on the indication and type of imaging modality, in the range of 1% to 5% [65-71]. The clinical significance of these incidental pleural effusions is variable. In a retrospective study of patients undergoing run-off CTA, 4.2% (9/214) had an incidental pleural effusion, leading to the diagnosis of pneumonia in 22% (2/9) and optimization of heart failure therapy in 44% (4/9) [72]. However, in a study of 352 patients undergoing MRA of the abdomen, pelvis, and lower extremities, 2.9% had an incidental pleural effusion, and no patients required follow-up diagnostic testing or change in therapy. CT Chest With IV Contrast There is no relevant literature to support the use of CT chest with IV contrast as the next imaging study following a pleural effusion incidentally detected on prior abdominal imaging. The recommendation for a follow-up CT chest with IV contrast should be based on clinical assessment (eg, clinical suspicion of malignancy). CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast as the next imaging study following a pleural effusion incidentally detected on prior abdominal imaging. The recommendation for a follow- up CT chest without and with IV contrast should be based on clinical assessment. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast as the next imaging study following a pleural effusion incidentally detected on prior abdominal imaging. The recommendation for a follow-up CT chest without IV contrast should be based on clinical assessment (eg, clinical suspicion of malignancy). | 3158179 |
acrac_3083061_0 | Thoracic Outlet Syndrome | Introduction/Background Thoracic outlet syndrome (TOS) denotes the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. There are three distinct spaces that can be implicated in TOS. Narrowing of each space results in slightly different presentations because of differing severity of impingement on the transiting neurovascular structures [1,2]. The costoclavicular triangle consists of the clavicle superiorly, the anterior scalene muscle posteriorly, and the first rib inferiorly. All three neurovascular structures pass through this space. Narrowing of this space tends to cause venous symptoms, frequently denoted venous TOS (vTOS), with varying degrees of additional symptoms due to arterial or brachial plexus compression. The interscalene triangle consists of the anterior scalene muscle, middle scalene muscle, and first rib. Trunks of the brachial plexus and the subclavian artery pass through this space; narrowing here causes neurological dominant TOS (nTOS), arterial dominant (aTOS), or combinations of both. The pectoralis minor space, defined by the pectoralis minor muscle anteriorly and chest wall posteriorly, is essentially an extension of the thoracic outlet and can result in varying degrees of compression similar to the costoclavicular space. During extreme shoulder abduction, the costoclavicular space is naturally narrowed. Anatomical variants such as a cervical rib can cause narrowing of the scalene triangle. Other possible sources of compression include anomalous first rib, C7 transverse process, or post-traumatic changes from prior clavicular or rib fractures. In patients who perform activities that require repetitive upper-extremity movement, such as swimming or throwing, or in patients who are not involved in excessive overhand motion but who have an anatomic predisposition to TOS, repetitive stress can lead to symptoms of TOS [3]. | Thoracic Outlet Syndrome. Introduction/Background Thoracic outlet syndrome (TOS) denotes the clinical entity that occurs with compression of the brachial plexus, subclavian artery, and/or subclavian vein at the superior thoracic outlet. There are three distinct spaces that can be implicated in TOS. Narrowing of each space results in slightly different presentations because of differing severity of impingement on the transiting neurovascular structures [1,2]. The costoclavicular triangle consists of the clavicle superiorly, the anterior scalene muscle posteriorly, and the first rib inferiorly. All three neurovascular structures pass through this space. Narrowing of this space tends to cause venous symptoms, frequently denoted venous TOS (vTOS), with varying degrees of additional symptoms due to arterial or brachial plexus compression. The interscalene triangle consists of the anterior scalene muscle, middle scalene muscle, and first rib. Trunks of the brachial plexus and the subclavian artery pass through this space; narrowing here causes neurological dominant TOS (nTOS), arterial dominant (aTOS), or combinations of both. The pectoralis minor space, defined by the pectoralis minor muscle anteriorly and chest wall posteriorly, is essentially an extension of the thoracic outlet and can result in varying degrees of compression similar to the costoclavicular space. During extreme shoulder abduction, the costoclavicular space is naturally narrowed. Anatomical variants such as a cervical rib can cause narrowing of the scalene triangle. Other possible sources of compression include anomalous first rib, C7 transverse process, or post-traumatic changes from prior clavicular or rib fractures. In patients who perform activities that require repetitive upper-extremity movement, such as swimming or throwing, or in patients who are not involved in excessive overhand motion but who have an anatomic predisposition to TOS, repetitive stress can lead to symptoms of TOS [3]. | 3083061 |
acrac_3083061_1 | Thoracic Outlet Syndrome | The subclavius muscle may hypertrophy, further narrowing the costoclavicular space, and the repetitive stress leads to thickening and fibrosis, notably in the subclavian vein wall, with restrictive fibrotic tissue surrounding the vein. Eventually, there is damage of the intima, resulting in luminal narrowing and a scarred, thrombogenic surface within the vein. Arterial changes in TOS similarly include intimal damage and thrombosis, with additional concerns of distal embolization and aneurysm formation. Neurological symptoms include chronic arm and hand paresthesia, numbness, or weakness. Although the exact prevalence of TOS is unknown, symptomatic TOS has been estimated to be 10 per 100,000 [4]. The current management of TOS is variable [5-11]. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes are important in choosing and interpreting radiological imaging, which may be performed to help diagnose TOS and plan for intervention. This document has separated imaging appropriateness based on neurogenic, arterial, or venous symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, a new symptom may indicate a complication. Consultation aResearch Author, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts. bMassachusetts General Hospital, Boston, Massachusetts. cPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. dPanel Chair, University of Chicago, Chicago, Illinois. ePanel Chair, University of Utah, Salt Lake City, Utah. fPanel Vice-Chair, Emory Healthcare, Atlanta, Georgia. gUC San Diego Health, San Diego, California. hThe University of Texas MD Anderson Cancer Center, Houston, Texas. iScripps Green Hospital, La Jolla, California; Society for Vascular Surgery. jMayo Clinic, Rochester, Minnesota. kUniversity of Alabama at Birmingham, Birmingham, Alabama. | Thoracic Outlet Syndrome. The subclavius muscle may hypertrophy, further narrowing the costoclavicular space, and the repetitive stress leads to thickening and fibrosis, notably in the subclavian vein wall, with restrictive fibrotic tissue surrounding the vein. Eventually, there is damage of the intima, resulting in luminal narrowing and a scarred, thrombogenic surface within the vein. Arterial changes in TOS similarly include intimal damage and thrombosis, with additional concerns of distal embolization and aneurysm formation. Neurological symptoms include chronic arm and hand paresthesia, numbness, or weakness. Although the exact prevalence of TOS is unknown, symptomatic TOS has been estimated to be 10 per 100,000 [4]. The current management of TOS is variable [5-11]. Understanding the various anatomic spaces, causes of narrowing, and resulting neurovascular changes are important in choosing and interpreting radiological imaging, which may be performed to help diagnose TOS and plan for intervention. This document has separated imaging appropriateness based on neurogenic, arterial, or venous symptoms, acknowledging that some patients may present with combined symptoms that may require more than one study to fully resolve. Additionally, in the postoperative setting, a new symptom may indicate a complication. Consultation aResearch Author, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts. bMassachusetts General Hospital, Boston, Massachusetts. cPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. dPanel Chair, University of Chicago, Chicago, Illinois. ePanel Chair, University of Utah, Salt Lake City, Utah. fPanel Vice-Chair, Emory Healthcare, Atlanta, Georgia. gUC San Diego Health, San Diego, California. hThe University of Texas MD Anderson Cancer Center, Houston, Texas. iScripps Green Hospital, La Jolla, California; Society for Vascular Surgery. jMayo Clinic, Rochester, Minnesota. kUniversity of Alabama at Birmingham, Birmingham, Alabama. | 3083061 |
acrac_3083061_2 | Thoracic Outlet Syndrome | lMayo Clinic, Rochester, Minnesota. mUniversity of Virginia, Charlottesville, Virginia. nUniversity of California Los Angeles, Los Angeles, California; American Academy of Neurology. oVanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians. pLoyola University Medical Center, Maywood, Illinois. qUT Southwestern Medical Center, Dallas, Texas. rDuke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons. sUT Southwestern Medical Center, Dallas, Texas. tSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia. uSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. vSpecialty Chair, UMass Memorial Medical Center, Worcester, Massachusetts. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Thoracic Outlet Syndrome with a radiologist may be useful at the time of examination ordering to optimize the study for the prevailing clinical symptom. When contrast is indicated, scan acquisition is typically performed with a contralateral antecubital intravenous (IV) injection, with either an empiric scan delay of 15 to 20 seconds or bolus tracking over the ascending aorta [12,13]. Some centers add the additional step of placing the contralateral arm in abduction (with the symptomatic ipsilateral arm in the neutral position) in order to minimize streak artifact [14]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. | Thoracic Outlet Syndrome. lMayo Clinic, Rochester, Minnesota. mUniversity of Virginia, Charlottesville, Virginia. nUniversity of California Los Angeles, Los Angeles, California; American Academy of Neurology. oVanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians. pLoyola University Medical Center, Maywood, Illinois. qUT Southwestern Medical Center, Dallas, Texas. rDuke University School of Medicine, Durham, North Carolina; The Society of Thoracic Surgeons. sUT Southwestern Medical Center, Dallas, Texas. tSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia. uSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. vSpecialty Chair, UMass Memorial Medical Center, Worcester, Massachusetts. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Thoracic Outlet Syndrome with a radiologist may be useful at the time of examination ordering to optimize the study for the prevailing clinical symptom. When contrast is indicated, scan acquisition is typically performed with a contralateral antecubital intravenous (IV) injection, with either an empiric scan delay of 15 to 20 seconds or bolus tracking over the ascending aorta [12,13]. Some centers add the additional step of placing the contralateral arm in abduction (with the symptomatic ipsilateral arm in the neutral position) in order to minimize streak artifact [14]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA, however, is 3-D rendering a required element. | 3083061 |
acrac_3083061_3 | Thoracic Outlet Syndrome | This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. CT venography (CTV) is obtained separately for each arm position 120 to 180 seconds after IV injection of iodinated contrast [6] in order to obtain venous opacification. The contrast injection should be performed in either the contralateral arm or other location. Multiplanar reformations are then produced to evaluate the thoracic space and true axial compression of the vessel. Center-line and volume-rendered images may also be produced to aid in visualization. CTA chest and CTV chest specifically denote studies tailored to evaluating the chest and thoracic outlet. These include evaluation of central vessels as well as subclavian and axillary arteries and veins, respectively. This is distinct from CTA upper extremity and CTV upper-extremity protocols, which are designed to evaluate the entire limb peripherally to the level of the wrist. Contrast-enhanced 3-D MR angiography (MRA) techniques have been described at both 1.5T and 3T to assess for TOS [19]. Breath-hold arterial phase contrast-enhanced 3-D MRA and equilibrium phase imaging is obtained using a 3-D gradient-echo pulse sequence with fat suppression. These can be obtained in both neutral and stressed positions with the exact protocol customized to institutional needs. A coronal oblique 3-D slab of the MRA is often obtained covering bilateral subclavian and axillary vessels. Unenhanced mask imaging is followed by multiphase contrast-enhanced dynamic acquisition in the same orientation. Noncontrast time-of-flight MRA may be considered, particularly in patients with contraindications to gadolinium-based contrast; however, these techniques suffer from flow artifacts, which could lead to false diagnosis of stenosis or thrombosis [19]. Noncontrast MRA Thoracic Outlet Syndrome also requires long acquisition times when combined with postural maneuvers that may be difficult to achieve for patients with severe clinical symptoms. | Thoracic Outlet Syndrome. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes. CT venography (CTV) is obtained separately for each arm position 120 to 180 seconds after IV injection of iodinated contrast [6] in order to obtain venous opacification. The contrast injection should be performed in either the contralateral arm or other location. Multiplanar reformations are then produced to evaluate the thoracic space and true axial compression of the vessel. Center-line and volume-rendered images may also be produced to aid in visualization. CTA chest and CTV chest specifically denote studies tailored to evaluating the chest and thoracic outlet. These include evaluation of central vessels as well as subclavian and axillary arteries and veins, respectively. This is distinct from CTA upper extremity and CTV upper-extremity protocols, which are designed to evaluate the entire limb peripherally to the level of the wrist. Contrast-enhanced 3-D MR angiography (MRA) techniques have been described at both 1.5T and 3T to assess for TOS [19]. Breath-hold arterial phase contrast-enhanced 3-D MRA and equilibrium phase imaging is obtained using a 3-D gradient-echo pulse sequence with fat suppression. These can be obtained in both neutral and stressed positions with the exact protocol customized to institutional needs. A coronal oblique 3-D slab of the MRA is often obtained covering bilateral subclavian and axillary vessels. Unenhanced mask imaging is followed by multiphase contrast-enhanced dynamic acquisition in the same orientation. Noncontrast time-of-flight MRA may be considered, particularly in patients with contraindications to gadolinium-based contrast; however, these techniques suffer from flow artifacts, which could lead to false diagnosis of stenosis or thrombosis [19]. Noncontrast MRA Thoracic Outlet Syndrome also requires long acquisition times when combined with postural maneuvers that may be difficult to achieve for patients with severe clinical symptoms. | 3083061 |
acrac_3083061_4 | Thoracic Outlet Syndrome | Contrast-enhanced 3-D MR venography (MRV) techniques have been described at both 1.5T and 3T to assess for vTOS [19]. Breath-hold venous phase contrast-enhanced 3-D MRV and equilibrium phase imaging is obtained using a 3-D gradient-echo pulse sequence with fat suppression. These can be obtained in both neutral and stressed positions with the exact protocol customized to institutional needs. A coronal oblique 3-D slab is often obtained covering bilateral subclavian and axillary vessels. Unenhanced mask imaging is followed by multiphase contrast- enhanced dynamic acquisition in the same orientation. Noncontrast time-of-flight MRV may be considered, particularly in patients with contraindications to gadolinium-based contrast; however, these techniques suffer from flow artifacts that could lead to false diagnosis of stenosis or thrombosis [19]. Noncontrast MRV also requires long acquisition times when combined with postural maneuvers that may be difficult to achieve for patients with severe clinical symptoms. CTA chest and CTV chest specifically denote studies tailored to evaluate the chest and thoracic outlet. These include evaluation of central vessels as well as subclavian and axillary arteries and veins, respectively. This is distinct from CTA upper extremity and CTV upper-extremity protocols, which are designed to evaluate the entire limb peripherally to the level of the wrist. Discussion of Procedures by Variant Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention. Arteriography Upper Extremity Selective upper-extremity arteriography is unable to directly image neurologic structures. This procedure is therefore not considered a first-line test for nTOS pre- or postoperatively. Catheter Venography Upper Extremity Dedicated endovascular catheter venography is unable to directly image neurologic structures. This procedure is therefore not considered a first-line test for nTOS pre- or postoperatively. | Thoracic Outlet Syndrome. Contrast-enhanced 3-D MR venography (MRV) techniques have been described at both 1.5T and 3T to assess for vTOS [19]. Breath-hold venous phase contrast-enhanced 3-D MRV and equilibrium phase imaging is obtained using a 3-D gradient-echo pulse sequence with fat suppression. These can be obtained in both neutral and stressed positions with the exact protocol customized to institutional needs. A coronal oblique 3-D slab is often obtained covering bilateral subclavian and axillary vessels. Unenhanced mask imaging is followed by multiphase contrast- enhanced dynamic acquisition in the same orientation. Noncontrast time-of-flight MRV may be considered, particularly in patients with contraindications to gadolinium-based contrast; however, these techniques suffer from flow artifacts that could lead to false diagnosis of stenosis or thrombosis [19]. Noncontrast MRV also requires long acquisition times when combined with postural maneuvers that may be difficult to achieve for patients with severe clinical symptoms. CTA chest and CTV chest specifically denote studies tailored to evaluate the chest and thoracic outlet. These include evaluation of central vessels as well as subclavian and axillary arteries and veins, respectively. This is distinct from CTA upper extremity and CTV upper-extremity protocols, which are designed to evaluate the entire limb peripherally to the level of the wrist. Discussion of Procedures by Variant Variant 1: Neurogenic thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention. Arteriography Upper Extremity Selective upper-extremity arteriography is unable to directly image neurologic structures. This procedure is therefore not considered a first-line test for nTOS pre- or postoperatively. Catheter Venography Upper Extremity Dedicated endovascular catheter venography is unable to directly image neurologic structures. This procedure is therefore not considered a first-line test for nTOS pre- or postoperatively. | 3083061 |
acrac_3083061_5 | Thoracic Outlet Syndrome | CT Chest CT for the evaluation of nTOS is limited by the lack of resolution of neural structures, although evaluation of the space sizes gives secondary indicators that may aid in diagnosis [13]. The goal is to demonstrate anatomical narrowing that could cause neurovascular compression. Findings include effacement of fat within the respective space and distortion or narrowing of the space with provocative or stress positioning. To also define adjacent vascular structures, a CT with IV contrast is sufficient for evaluation of nTOS [12,13]. CT allows quantification of the change in costoclavicular or interscalene spaces with provocative maneuvers [12,13], the presence of bony abnormalities [20,21], or superior sulcus pathology [22]. CT without IV contrast may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. If there is a clinical concern for arterial or venous compromise, postintervention for patients with nTOS, imaging should be guided by those Variants. CTA Chest CTA does not provide further evaluation of the neurologic structures as compared with chest CT. If there are overlapping symptoms with aTOS or vTOS, review of the other Variants in this document may help with protocol optimization. CTV Chest CTV does not provide further evaluation of the neurologic structures as compared with chest CT. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. MRI Chest MRI has inherent advantages over ultrasound (US) in its ability to delineate extravascular anatomy, particularly in anatomic sites with poor sonographic windows, and MRI has advantages over CT in its characterization and differentiation of soft tissues. Thoracic Outlet Syndrome | Thoracic Outlet Syndrome. CT Chest CT for the evaluation of nTOS is limited by the lack of resolution of neural structures, although evaluation of the space sizes gives secondary indicators that may aid in diagnosis [13]. The goal is to demonstrate anatomical narrowing that could cause neurovascular compression. Findings include effacement of fat within the respective space and distortion or narrowing of the space with provocative or stress positioning. To also define adjacent vascular structures, a CT with IV contrast is sufficient for evaluation of nTOS [12,13]. CT allows quantification of the change in costoclavicular or interscalene spaces with provocative maneuvers [12,13], the presence of bony abnormalities [20,21], or superior sulcus pathology [22]. CT without IV contrast may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. If there is a clinical concern for arterial or venous compromise, postintervention for patients with nTOS, imaging should be guided by those Variants. CTA Chest CTA does not provide further evaluation of the neurologic structures as compared with chest CT. If there are overlapping symptoms with aTOS or vTOS, review of the other Variants in this document may help with protocol optimization. CTV Chest CTV does not provide further evaluation of the neurologic structures as compared with chest CT. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. MRI Chest MRI has inherent advantages over ultrasound (US) in its ability to delineate extravascular anatomy, particularly in anatomic sites with poor sonographic windows, and MRI has advantages over CT in its characterization and differentiation of soft tissues. Thoracic Outlet Syndrome | 3083061 |
acrac_3083061_6 | Thoracic Outlet Syndrome | For evaluation of patients with nTOS, definition of the brachial plexus and cervical spine and dynamic evaluation of neurovascular bundles in the costoclavicular, interscalene, and pectoralis minor spaces are required. Noncontrast MRI can be sufficient to diagnose nTOS. In one study, for patients with nTOS, the neurovascular bundle was most commonly compressed in the costoclavicular space, mostly secondary to position, and very rarely compressed in the pectoralis minor space [16]. The cause of TOS was congenital bone variations in 36%, congenital fibromuscular anomalies in 11%, and positional in 53%. In 5%, there was unilateral brachial plexitis in addition to compression of the neurovascular bundle. Severe cervical spondylosis was noted in 14%, contributing to TOS symptoms [16]. MRI without IV contrast may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. Postcontrast imaging may additionally be useful to assess the soft tissues for inflammatory or neoplastic conditions. MRA Chest Contrast-enhanced 3-D MRA techniques do not provide evaluation of the neurologic structures. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. MRV Chest Contrast-enhanced 3-D MRV techniques do not provide adequate evaluation of the neurologic structures. This procedure is therefore not considered a first-line test for nTOS pre- or postoperatively. Radiography Chest Chest radiography is frequently used as an initial imaging modality in suspected TOS. Osseous abnormalities associated with TOS are frequently easily diagnosed by chest radiographs. These include first rib anomalies [20], cervical ribs [23], congenital osseous malformations [24,25], and focal bone lesions [26]. | Thoracic Outlet Syndrome. For evaluation of patients with nTOS, definition of the brachial plexus and cervical spine and dynamic evaluation of neurovascular bundles in the costoclavicular, interscalene, and pectoralis minor spaces are required. Noncontrast MRI can be sufficient to diagnose nTOS. In one study, for patients with nTOS, the neurovascular bundle was most commonly compressed in the costoclavicular space, mostly secondary to position, and very rarely compressed in the pectoralis minor space [16]. The cause of TOS was congenital bone variations in 36%, congenital fibromuscular anomalies in 11%, and positional in 53%. In 5%, there was unilateral brachial plexitis in addition to compression of the neurovascular bundle. Severe cervical spondylosis was noted in 14%, contributing to TOS symptoms [16]. MRI without IV contrast may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. Postcontrast imaging may additionally be useful to assess the soft tissues for inflammatory or neoplastic conditions. MRA Chest Contrast-enhanced 3-D MRA techniques do not provide evaluation of the neurologic structures. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. MRV Chest Contrast-enhanced 3-D MRV techniques do not provide adequate evaluation of the neurologic structures. This procedure is therefore not considered a first-line test for nTOS pre- or postoperatively. Radiography Chest Chest radiography is frequently used as an initial imaging modality in suspected TOS. Osseous abnormalities associated with TOS are frequently easily diagnosed by chest radiographs. These include first rib anomalies [20], cervical ribs [23], congenital osseous malformations [24,25], and focal bone lesions [26]. | 3083061 |
acrac_3083061_7 | Thoracic Outlet Syndrome | Soft-tissue lesions, such as lung neoplasms [27], may also be evaluated, although the negative predictive value of chest radiographs is low, such that cross-sectional imaging is a necessary part of a complete TOS workup. In the postoperative setting, radiographs may be useful to confirm osseous changes and evaluate for postoperative complications, such as pneumothorax. US Duplex Doppler Subclavian Artery and Vein US is widely used as an imaging modality in the initial evaluation of patients with suspected arterial or venous pathology. Although many patients with nTOS have additional symptoms due to arterial or venous compression, US is not as valuable in assessing direct neurological involvement. Real-time duplex US can be used to evaluate the cross-sectional area of the costocervical space with and without provocative maneuvers [28]. Diagnosis of compressive effects upon the brachial plexus is a challenge [29], and symptoms of TOS may unmask a deeper regional pathology such as a Pancoast tumor or cervical spondylopathy, requiring further imaging. If there is reason to believe that symptoms could be related to hypertrophy of the anterior scalene muscles, US could be used for guidance to inject anesthetic in an attempt to confirm nTOS [30]. The procedure is considered diagnostic of nTOS if the patient experiences relief of symptoms after the injection. In the postoperative setting, US can be useful to evaluate vessel patency and complications such as postoperative hematoma or fluid collection. Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention. Arteriography Upper Extremity Selective upper-extremity arteriography may be used to evaluate extrinsic compression of the subclavian artery; however, it does not provide diagnostic assessment of the subclavian vein. This procedure is therefore not considered a first-line test for vTOS. | Thoracic Outlet Syndrome. Soft-tissue lesions, such as lung neoplasms [27], may also be evaluated, although the negative predictive value of chest radiographs is low, such that cross-sectional imaging is a necessary part of a complete TOS workup. In the postoperative setting, radiographs may be useful to confirm osseous changes and evaluate for postoperative complications, such as pneumothorax. US Duplex Doppler Subclavian Artery and Vein US is widely used as an imaging modality in the initial evaluation of patients with suspected arterial or venous pathology. Although many patients with nTOS have additional symptoms due to arterial or venous compression, US is not as valuable in assessing direct neurological involvement. Real-time duplex US can be used to evaluate the cross-sectional area of the costocervical space with and without provocative maneuvers [28]. Diagnosis of compressive effects upon the brachial plexus is a challenge [29], and symptoms of TOS may unmask a deeper regional pathology such as a Pancoast tumor or cervical spondylopathy, requiring further imaging. If there is reason to believe that symptoms could be related to hypertrophy of the anterior scalene muscles, US could be used for guidance to inject anesthetic in an attempt to confirm nTOS [30]. The procedure is considered diagnostic of nTOS if the patient experiences relief of symptoms after the injection. In the postoperative setting, US can be useful to evaluate vessel patency and complications such as postoperative hematoma or fluid collection. Variant 2: Venous thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention. Arteriography Upper Extremity Selective upper-extremity arteriography may be used to evaluate extrinsic compression of the subclavian artery; however, it does not provide diagnostic assessment of the subclavian vein. This procedure is therefore not considered a first-line test for vTOS. | 3083061 |
acrac_3083061_8 | Thoracic Outlet Syndrome | In the postprocedure setting, catheter arteriography may be performed to evaluate and intervene on suspected or confirmed arterial complications. Catheter Venography Upper Extremity Diagnostic venography may be performed for suspected vTOS in which the veins of the affected extremity are catheterized, and contrast injection is performed via the catheter during digital subtraction acquisition in both neutral and stressed positions. Typical findings include narrowing of the subclavian vein with appearance of venous collateral vessels. These are generally seen projecting over the thorax or across the neck. Total occlusion of the subclavian vein may be present in chronic or acute TOS, and all findings may be present on only stressed position venography or at stress and neutral positions. Thoracic Outlet Syndrome As part of the evaluation for surgical decompression, patients may also undergo contralateral venography as well as catheter-directed thrombolysis. Angioplasty is not typically performed in the chronic setting, and at some centers, it is generally avoided prior to surgical decompression. In patients with total or near-total subclavian vein occlusion, endovascular recanalization of the subclavian vein may be attempted, and, if successful, a peripherally inserted central venous catheter is occasionally inserted and positioned so that it courses across the newly recanalized venous segment. It is then left indwelling until after surgical decompression is performed so as to preserve a route of intraluminal access across the diseased subclavian vein segment. One advantage of venography as a diagnostic tool is that other presurgery interventions may be performed, including intravascular thrombolysis, thrombectomy, and angioplasty. For postsurgical decompression, catheter venography is often indicated for evaluation of residual narrowing and possible US angioplasty of the diseased or stenosed segment with the external compression [31,32]. | Thoracic Outlet Syndrome. In the postprocedure setting, catheter arteriography may be performed to evaluate and intervene on suspected or confirmed arterial complications. Catheter Venography Upper Extremity Diagnostic venography may be performed for suspected vTOS in which the veins of the affected extremity are catheterized, and contrast injection is performed via the catheter during digital subtraction acquisition in both neutral and stressed positions. Typical findings include narrowing of the subclavian vein with appearance of venous collateral vessels. These are generally seen projecting over the thorax or across the neck. Total occlusion of the subclavian vein may be present in chronic or acute TOS, and all findings may be present on only stressed position venography or at stress and neutral positions. Thoracic Outlet Syndrome As part of the evaluation for surgical decompression, patients may also undergo contralateral venography as well as catheter-directed thrombolysis. Angioplasty is not typically performed in the chronic setting, and at some centers, it is generally avoided prior to surgical decompression. In patients with total or near-total subclavian vein occlusion, endovascular recanalization of the subclavian vein may be attempted, and, if successful, a peripherally inserted central venous catheter is occasionally inserted and positioned so that it courses across the newly recanalized venous segment. It is then left indwelling until after surgical decompression is performed so as to preserve a route of intraluminal access across the diseased subclavian vein segment. One advantage of venography as a diagnostic tool is that other presurgery interventions may be performed, including intravascular thrombolysis, thrombectomy, and angioplasty. For postsurgical decompression, catheter venography is often indicated for evaluation of residual narrowing and possible US angioplasty of the diseased or stenosed segment with the external compression [31,32]. | 3083061 |
acrac_3083061_9 | Thoracic Outlet Syndrome | Intravascular US (IVUS) may be used as an adjunct in the postoperative setting to evaluate residual lumen size and presence of webs and has been shown to detect a higher degree of stenosis compared with venography alone [33]. CT Chest For noncontrast chest CT, the goal is to demonstrate anatomical narrowing that could cause vascular compression. Findings include effacement of fat within the respective space and distortion or narrowing of the space with provocative or stress positioning. Given the enhanced visualization of vascular structures with contrast, chest CT with IV contrast is preferred for evaluation of vTOS, and the acquisition is typically performed with a contralateral antecubital injection of contrast material. Chest CT without IV contrast may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. However, chest CT with IV contrast has the advantage of providing assessment of vascular patency, which is a potential complication in the postintervention setting for patients with vTOS. CTA Chest CTA is performed to evaluate arterial compression and is therefore of limited use in the evaluation of vTOS. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. CTV Chest CTV is performed to evaluate venous compression in neutral and elevated arm positions. Venous compression is often present with abduction in asymptomatic patients, and therefore this finding alone may be insufficient to diagnose vTOS. Venous thrombosis and presence of collateral venous circulation essentially bypassing the thoracic outlet confirms the existence of hemodynamically significant vTOS [1]. | Thoracic Outlet Syndrome. Intravascular US (IVUS) may be used as an adjunct in the postoperative setting to evaluate residual lumen size and presence of webs and has been shown to detect a higher degree of stenosis compared with venography alone [33]. CT Chest For noncontrast chest CT, the goal is to demonstrate anatomical narrowing that could cause vascular compression. Findings include effacement of fat within the respective space and distortion or narrowing of the space with provocative or stress positioning. Given the enhanced visualization of vascular structures with contrast, chest CT with IV contrast is preferred for evaluation of vTOS, and the acquisition is typically performed with a contralateral antecubital injection of contrast material. Chest CT without IV contrast may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. However, chest CT with IV contrast has the advantage of providing assessment of vascular patency, which is a potential complication in the postintervention setting for patients with vTOS. CTA Chest CTA is performed to evaluate arterial compression and is therefore of limited use in the evaluation of vTOS. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. CTV Chest CTV is performed to evaluate venous compression in neutral and elevated arm positions. Venous compression is often present with abduction in asymptomatic patients, and therefore this finding alone may be insufficient to diagnose vTOS. Venous thrombosis and presence of collateral venous circulation essentially bypassing the thoracic outlet confirms the existence of hemodynamically significant vTOS [1]. | 3083061 |
acrac_3083061_10 | Thoracic Outlet Syndrome | Multiple studies have demonstrated the utility of CTV with IV contrast in evaluation of the upper-limb veins; however, reliance on axial slices alone can lead to misrepresentation of the degree of any stenosis, with one study showing underestimation of stenosis found in 43% of transverse CT scans but only in 10% of sagittal reformations. Overestimation of stenosis was also more frequent on surface displays with 3-D shading (16%) than on volume- rendered images (7%) [12], thus advancing the case for evaluation of these studies using these multiplanar tools in addition to standard reformations. CTV may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and follow-up on vessel patency or complications. Recurrent or persistent venous thrombosis may require reintervention. MRI Chest MRI for vTOS is performed to delineate anatomy and evaluate the pertinent anatomic spaces in both neutral and arms-abducted positions. Noncontrast MRI findings include effacement of fat adjacent to the subclavian vein. T1- weighted imaging performed in sagittal and axial planes can also demonstrate causative lesions, including cervical ribs, congenital fibromuscular anomalies, and muscular hypertrophy. Venous compression has been routinely demonstrated in all 3 compartments of the thoracic outlet in both asymptomatic and symptomatic populations when the arms were abducted [17]. Therefore, a finding of compression on abduction must be interpreted carefully. In symptomatic patients, venous thrombosis and collateral circulation Thoracic Outlet Syndrome are detected in both neutral and stressed arm positions, suggesting these findings are more reliably diagnostic of vTOS. They represent an objective, but likely chronic, finding of clinically significant venous compression. | Thoracic Outlet Syndrome. Multiple studies have demonstrated the utility of CTV with IV contrast in evaluation of the upper-limb veins; however, reliance on axial slices alone can lead to misrepresentation of the degree of any stenosis, with one study showing underestimation of stenosis found in 43% of transverse CT scans but only in 10% of sagittal reformations. Overestimation of stenosis was also more frequent on surface displays with 3-D shading (16%) than on volume- rendered images (7%) [12], thus advancing the case for evaluation of these studies using these multiplanar tools in addition to standard reformations. CTV may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and follow-up on vessel patency or complications. Recurrent or persistent venous thrombosis may require reintervention. MRI Chest MRI for vTOS is performed to delineate anatomy and evaluate the pertinent anatomic spaces in both neutral and arms-abducted positions. Noncontrast MRI findings include effacement of fat adjacent to the subclavian vein. T1- weighted imaging performed in sagittal and axial planes can also demonstrate causative lesions, including cervical ribs, congenital fibromuscular anomalies, and muscular hypertrophy. Venous compression has been routinely demonstrated in all 3 compartments of the thoracic outlet in both asymptomatic and symptomatic populations when the arms were abducted [17]. Therefore, a finding of compression on abduction must be interpreted carefully. In symptomatic patients, venous thrombosis and collateral circulation Thoracic Outlet Syndrome are detected in both neutral and stressed arm positions, suggesting these findings are more reliably diagnostic of vTOS. They represent an objective, but likely chronic, finding of clinically significant venous compression. | 3083061 |
acrac_3083061_11 | Thoracic Outlet Syndrome | Given the need to assess the subclavian vein as well as venous collaterals in vTOS, noncontrast MRI is insufficient alone; the addition of IV contrast, particularly when an MRV protocol is performed, provides optimal assessment. The combination of soft-tissue and vascular assessment provided by MRI with IV contrast makes it an excellent modality when compared with US and CT; however, the longer acquisition times may prove difficult for highly symptomatic patients. MRI with IV contrast may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. MRA Chest MRA is not optimized for evaluation of the venous structures. If there are overlapping symptoms, review of the other variants in this document may help with protocol optimization. Interestingly, in one study [19], all patients with arterial compression were found to have venous compression during arm abduction. In patients with venous compression on one side, 71% had significant bilateral venous compression. Of these patients with bilateral imaging findings, only 21% had bilateral clinical symptoms or findings suggestive of TOS. Therefore, MRA has the potential to overdiagnose vTOS, and clinical symptoms must be taken into account. MRA may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and confirm arterial patency. MRV Chest MRV is commonly performed in conjunction with MRI chest [34-36]. The primary MRV finding is narrowing of the subclavian vein; however, other findings, such as complete occlusion, collateral vessel formation, and visualization of thrombus, aid in the diagnosis of vTOS. Interestingly, in one study [19], all patients with arterial compression were found to have venous compression during arm abduction. In patients with venous compression on one side, 71% had significant bilateral venous compression. | Thoracic Outlet Syndrome. Given the need to assess the subclavian vein as well as venous collaterals in vTOS, noncontrast MRI is insufficient alone; the addition of IV contrast, particularly when an MRV protocol is performed, provides optimal assessment. The combination of soft-tissue and vascular assessment provided by MRI with IV contrast makes it an excellent modality when compared with US and CT; however, the longer acquisition times may prove difficult for highly symptomatic patients. MRI with IV contrast may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. MRA Chest MRA is not optimized for evaluation of the venous structures. If there are overlapping symptoms, review of the other variants in this document may help with protocol optimization. Interestingly, in one study [19], all patients with arterial compression were found to have venous compression during arm abduction. In patients with venous compression on one side, 71% had significant bilateral venous compression. Of these patients with bilateral imaging findings, only 21% had bilateral clinical symptoms or findings suggestive of TOS. Therefore, MRA has the potential to overdiagnose vTOS, and clinical symptoms must be taken into account. MRA may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and confirm arterial patency. MRV Chest MRV is commonly performed in conjunction with MRI chest [34-36]. The primary MRV finding is narrowing of the subclavian vein; however, other findings, such as complete occlusion, collateral vessel formation, and visualization of thrombus, aid in the diagnosis of vTOS. Interestingly, in one study [19], all patients with arterial compression were found to have venous compression during arm abduction. In patients with venous compression on one side, 71% had significant bilateral venous compression. | 3083061 |
acrac_3083061_12 | Thoracic Outlet Syndrome | Of these patients with bilateral imaging findings, only 21% had bilateral clinical symptoms or findings suggestive of TOS. Therefore, MRV has the potential to overdiagnose vTOS, and clinical symptoms must be taken into account. MRV may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and confirm arterial patency. Radiography Chest Because of the importance of identifying osseous structures that may impinge on the spaces of the thoracic outlet, chest radiography is useful in performing a robust evaluation for all types of TOS. As opposed to directly evaluating vascular structures, osseous abnormalities associated with TOS are frequently easily diagnosed by chest radiographs. These include first rib anomalies [20], cervical ribs [23], congenital osseous malformations [24,25], and focal bone lesions [26]. In the postoperative setting, radiographs may be useful to confirm osseous changes and evaluate for postoperative complications such as pneumothorax. US has a longstanding and well-documented role in the diagnosis of upper-extremity DVT [5,39], a common presentation of vTOS in the acute setting. Although the main advantage of US is the ability to directly compare between provocatively induced symptoms and concurrent direct vessel visualization, there is debate in the literature as to the significance of imaging findings, particularly with respect to maneuvers to minimize the thoracic outlet and associated spaces [28,37,40]. It is important to consider that certain etiologies of vTOS due to deeper pathology, such as Pancoast tumor or cervical spondylopathy, may require further investigation with cross-sectional imaging. Thoracic Outlet Syndrome In the postoperative setting, US can be useful to evaluate vessel patency and complications, such as postoperative hematoma or fluid collection. Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention. | Thoracic Outlet Syndrome. Of these patients with bilateral imaging findings, only 21% had bilateral clinical symptoms or findings suggestive of TOS. Therefore, MRV has the potential to overdiagnose vTOS, and clinical symptoms must be taken into account. MRV may also be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and confirm arterial patency. Radiography Chest Because of the importance of identifying osseous structures that may impinge on the spaces of the thoracic outlet, chest radiography is useful in performing a robust evaluation for all types of TOS. As opposed to directly evaluating vascular structures, osseous abnormalities associated with TOS are frequently easily diagnosed by chest radiographs. These include first rib anomalies [20], cervical ribs [23], congenital osseous malformations [24,25], and focal bone lesions [26]. In the postoperative setting, radiographs may be useful to confirm osseous changes and evaluate for postoperative complications such as pneumothorax. US has a longstanding and well-documented role in the diagnosis of upper-extremity DVT [5,39], a common presentation of vTOS in the acute setting. Although the main advantage of US is the ability to directly compare between provocatively induced symptoms and concurrent direct vessel visualization, there is debate in the literature as to the significance of imaging findings, particularly with respect to maneuvers to minimize the thoracic outlet and associated spaces [28,37,40]. It is important to consider that certain etiologies of vTOS due to deeper pathology, such as Pancoast tumor or cervical spondylopathy, may require further investigation with cross-sectional imaging. Thoracic Outlet Syndrome In the postoperative setting, US can be useful to evaluate vessel patency and complications, such as postoperative hematoma or fluid collection. Variant 3: Arterial thoracic outlet syndrome. Initial imaging and follow-up imaging after surgery or intervention. | 3083061 |
acrac_3083061_13 | Thoracic Outlet Syndrome | Arteriography Upper Extremity Conventional catheter-based arteriography is effective at locating the exact point of vascular compression. In order to perform complete arteriography, catheter injection of contrast must be made from the aortic arch or the proximal subclavian artery. Injections and digital subtraction angiographic acquisitions are performed in both the neutral and abducted positions to assess dynamic changes. Vascular access is typically obtained from the femoral artery, although a radial artery approach can be considered. Even as a diagnostic tool alone, arteriography carries some risk. Because of its invasive nature and lack of information regarding surrounding structures, catheter-based angiography is largely only pursued if an endovascular intervention is envisioned. In the postintervention setting, catheter arteriography can provide definitive evaluation of arterial compression, occlusion, or other complication, such as dissection or aneurysm formation. This modality has the added advantage of possible immediate endovascular intervention. Catheter Venography Upper Extremity Diagnostic venography is not optimized for arterial evaluation. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. CT Chest For noncontrast CT, the goal is to demonstrate anatomical narrowing that could cause vascular compression. Findings include effacement of fat within the respective space and distortion or narrowing of the space with provocative or stress positioning. In a comprehensive study [13], a statistically significant difference was found between the distribution of the distances measured in the neutral and abducted positions in patients with arterial stenosis versus those without arterial stenosis. CT without IV contrast may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. | Thoracic Outlet Syndrome. Arteriography Upper Extremity Conventional catheter-based arteriography is effective at locating the exact point of vascular compression. In order to perform complete arteriography, catheter injection of contrast must be made from the aortic arch or the proximal subclavian artery. Injections and digital subtraction angiographic acquisitions are performed in both the neutral and abducted positions to assess dynamic changes. Vascular access is typically obtained from the femoral artery, although a radial artery approach can be considered. Even as a diagnostic tool alone, arteriography carries some risk. Because of its invasive nature and lack of information regarding surrounding structures, catheter-based angiography is largely only pursued if an endovascular intervention is envisioned. In the postintervention setting, catheter arteriography can provide definitive evaluation of arterial compression, occlusion, or other complication, such as dissection or aneurysm formation. This modality has the added advantage of possible immediate endovascular intervention. Catheter Venography Upper Extremity Diagnostic venography is not optimized for arterial evaluation. If there are overlapping symptoms, review of the other Variants in this document may help with protocol optimization. CT Chest For noncontrast CT, the goal is to demonstrate anatomical narrowing that could cause vascular compression. Findings include effacement of fat within the respective space and distortion or narrowing of the space with provocative or stress positioning. In a comprehensive study [13], a statistically significant difference was found between the distribution of the distances measured in the neutral and abducted positions in patients with arterial stenosis versus those without arterial stenosis. CT without IV contrast may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet and assess adequate decompression. | 3083061 |
acrac_3083061_14 | Thoracic Outlet Syndrome | However, CT with IV contrast has the advantage of providing assessment of vascular patency, which is a potential complication in postintervention setting for patients with aTOS. CTA Chest CTA is performed to evaluate arterial compression in neutral and elevated arm positions. An indentation of the anterior wall of the subclavian artery as it passes around the anterior scalene muscle may be observed [13] as well as displacement of the subclavian vessels. Arterial compression is assessed by using arterial cross-sections produced by sagittal reformation of data. Sagittal reformation can show the location and severity of the arterial compression, and volume-rendered images allow simultaneous analysis of bones and subclavian artery. Arterial stenosis is expressed as the percentage of reduction of the cross-sectional area or the diameter of the artery [1]. Multiple studies have demonstrated the utility of CT in evaluation of the upper-limb arteries and veins; however, reliance on axial slices alone can lead to misrepresentation of the degree of any stenosis, with one study showing underestimation of stenosis found in 43% of transverse CT scans but only 10% of sagittal reformations. Overestimation of stenosis was also more frequent on surface displays with 3-D shading (16%) than on volume rendered images (7%) [12], advancing the case for evaluation of these studies on vascular workstations. For arterial compression, there is evidence of good correlation of CT findings with operative findings and results of decompression [41]. CTA may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and follow-up vessel patency or complications. Recurrent or persistent venous thrombosis may require reintervention. CTV Chest CTV is performed for evaluation of venous compression. This specific modality is therefore of limited use in aTOS. | Thoracic Outlet Syndrome. However, CT with IV contrast has the advantage of providing assessment of vascular patency, which is a potential complication in postintervention setting for patients with aTOS. CTA Chest CTA is performed to evaluate arterial compression in neutral and elevated arm positions. An indentation of the anterior wall of the subclavian artery as it passes around the anterior scalene muscle may be observed [13] as well as displacement of the subclavian vessels. Arterial compression is assessed by using arterial cross-sections produced by sagittal reformation of data. Sagittal reformation can show the location and severity of the arterial compression, and volume-rendered images allow simultaneous analysis of bones and subclavian artery. Arterial stenosis is expressed as the percentage of reduction of the cross-sectional area or the diameter of the artery [1]. Multiple studies have demonstrated the utility of CT in evaluation of the upper-limb arteries and veins; however, reliance on axial slices alone can lead to misrepresentation of the degree of any stenosis, with one study showing underestimation of stenosis found in 43% of transverse CT scans but only 10% of sagittal reformations. Overestimation of stenosis was also more frequent on surface displays with 3-D shading (16%) than on volume rendered images (7%) [12], advancing the case for evaluation of these studies on vascular workstations. For arterial compression, there is evidence of good correlation of CT findings with operative findings and results of decompression [41]. CTA may be performed in the postintervention setting to evaluate interval changes in the thoracic outlet, assess adequate decompression, and follow-up vessel patency or complications. Recurrent or persistent venous thrombosis may require reintervention. CTV Chest CTV is performed for evaluation of venous compression. This specific modality is therefore of limited use in aTOS. | 3083061 |
Subsets and Splits