id
stringlengths 13
16
| title
stringclasses 225
values | content
stringlengths 1.09k
2.04k
| contents
stringlengths 1.12k
2.05k
| ACRID
stringclasses 225
values |
|---|---|---|---|---|
acrac_3091546_3 | Breast Pain | US Breast There is scant literature specifically evaluating the use of ultrasound (US) imaging in patients with nonfocal or cyclical breast pain. In a retrospective review of 236 patients with breast pain, authors found no mammographic or sonographic correlate in the 10 patients who had cyclical breast pain [8]. A prospective study of 76 patients younger than age 30 who presented with cyclical breast pain as their only complaint and underwent US found no malignancy [35]. A limitation of this study was the lack of follow-up. MRI Breast There is no relevant literature regarding the use of MRI in the evaluation of nonfocal or cyclical breast pain. Sestamibi MBI There is no relevant literature regarding the use of molecular breast imaging (MBI) in the evaluation of nonfocal or cyclical breast pain. Variant 2: Female with clinically significant breast pain (focal and noncyclical). Age less than 30. Initial imaging. Mammography There is little in the literature specifically evaluating the use of mammography in patients less than 30 years of age who have focal and noncyclical breast pain. Because of greater breast density, mammography is known to be less accurate than US in evaluating symptomatic women less than 30 years of age [36]. DBT DBT There is no relevant literature regarding the use of DBT in the evaluation of focal and noncyclical breast pain in patients less than 30 years of age. US Breast US Breast The literature regarding the efficacy of US in evaluation of breast pain is somewhat limited by lack of age-group- specific results. Most authors have found that cancer is a rare cause of focal, clinically significant breast pain [12,35], and that US has a high negative predictive value (NPV), sensitivity, and specificity for evaluation of breast pain. | Breast Pain. US Breast There is scant literature specifically evaluating the use of ultrasound (US) imaging in patients with nonfocal or cyclical breast pain. In a retrospective review of 236 patients with breast pain, authors found no mammographic or sonographic correlate in the 10 patients who had cyclical breast pain [8]. A prospective study of 76 patients younger than age 30 who presented with cyclical breast pain as their only complaint and underwent US found no malignancy [35]. A limitation of this study was the lack of follow-up. MRI Breast There is no relevant literature regarding the use of MRI in the evaluation of nonfocal or cyclical breast pain. Sestamibi MBI There is no relevant literature regarding the use of molecular breast imaging (MBI) in the evaluation of nonfocal or cyclical breast pain. Variant 2: Female with clinically significant breast pain (focal and noncyclical). Age less than 30. Initial imaging. Mammography There is little in the literature specifically evaluating the use of mammography in patients less than 30 years of age who have focal and noncyclical breast pain. Because of greater breast density, mammography is known to be less accurate than US in evaluating symptomatic women less than 30 years of age [36]. DBT DBT There is no relevant literature regarding the use of DBT in the evaluation of focal and noncyclical breast pain in patients less than 30 years of age. US Breast US Breast The literature regarding the efficacy of US in evaluation of breast pain is somewhat limited by lack of age-group- specific results. Most authors have found that cancer is a rare cause of focal, clinically significant breast pain [12,35], and that US has a high negative predictive value (NPV), sensitivity, and specificity for evaluation of breast pain. | 3091546 |
acrac_3091546_4 | Breast Pain | Leddy et al [11] performed a retrospective review of 257 patients who underwent US after presenting with focal breast pain and found cancer in 1.2% of patients, with a sensitivity of 100%, specificity of 92.5%, positive predictive value of 13.6%, and NPV of 100%. Loving et al [37] found a 100% NPV and sensitivity in their retrospective study of 830 patients less than 30 years of age with focal breast signs or symptoms (not limited to but including breast pain). Some authors suggest that, despite the low incidence of malignancy, US may be useful in that it could potentially find treatable causes of breast pain, such as cysts [9]. On the other hand, a prospective, observational follow-up study of 987 patients with breast pain alone found benign findings in 8.6% of cases, which consisted mostly of Breast Pain small cysts [14]. The authors argued that in the absence of a palpable abnormality, any cyst that may be found by US would be unlikely to be large enough to cause pain or benefit from aspiration. MRI Breast There is no relevant literature regarding the use of MRI in the evaluation of focal and noncyclical breast pain. Sestamibi MBI There is no relevant literature regarding the use of MBI in the evaluation of focal and noncyclical breast pain. Variant 3: Female with clinically significant breast pain (focal and noncyclical). Age 30 to 39. Initial imaging. Mammography Though the incidence is low, mammography may be used to exclude malignancy in cases of focal and noncyclical breast pain. Mammography was found to have a high sensitivity (100%) and NPV (100%) in a retrospective review of 206 patients with focal breast pain [11]. While this study found specificity to be slightly lower at 87.6%, another retrospective study of focal, noncyclical pain calculated a specificity of mammography of 97% for nondense breasts and 96% for dense breasts [9]. | Breast Pain. Leddy et al [11] performed a retrospective review of 257 patients who underwent US after presenting with focal breast pain and found cancer in 1.2% of patients, with a sensitivity of 100%, specificity of 92.5%, positive predictive value of 13.6%, and NPV of 100%. Loving et al [37] found a 100% NPV and sensitivity in their retrospective study of 830 patients less than 30 years of age with focal breast signs or symptoms (not limited to but including breast pain). Some authors suggest that, despite the low incidence of malignancy, US may be useful in that it could potentially find treatable causes of breast pain, such as cysts [9]. On the other hand, a prospective, observational follow-up study of 987 patients with breast pain alone found benign findings in 8.6% of cases, which consisted mostly of Breast Pain small cysts [14]. The authors argued that in the absence of a palpable abnormality, any cyst that may be found by US would be unlikely to be large enough to cause pain or benefit from aspiration. MRI Breast There is no relevant literature regarding the use of MRI in the evaluation of focal and noncyclical breast pain. Sestamibi MBI There is no relevant literature regarding the use of MBI in the evaluation of focal and noncyclical breast pain. Variant 3: Female with clinically significant breast pain (focal and noncyclical). Age 30 to 39. Initial imaging. Mammography Though the incidence is low, mammography may be used to exclude malignancy in cases of focal and noncyclical breast pain. Mammography was found to have a high sensitivity (100%) and NPV (100%) in a retrospective review of 206 patients with focal breast pain [11]. While this study found specificity to be slightly lower at 87.6%, another retrospective study of focal, noncyclical pain calculated a specificity of mammography of 97% for nondense breasts and 96% for dense breasts [9]. | 3091546 |
acrac_3091546_5 | Breast Pain | Additionally, Tumyan et al [38] in a retrospective study of mammography in combination with US found a NPV of 100%, though the study was limited by a significant number of patients being lost to follow-up. DBT DBT While there is no literature specifically evaluating the use of DBT in the workup of focal and noncyclical breast pain, DBT can be useful in the diagnostic setting. It is known to improve lesion characterization in noncalcified lesions and cancer detection when compared to conventional mammographic workup [28-30,39-41]. US Breast While there are few studies evaluating US independently of mammography in the setting of focal and noncyclical breast pain, the existing literature suggests that US may be useful to exclude malignancy in these cases. A retrospective review of 110 cases of focal breast pain evaluated by US found no imaging abnormality in 85 cases (77.3%) [12] and there were no malignancies. In 15 cases (13.6%), cysts were identified, and 3 patients (2.7%) had solid masses, all of which were benign. Fluid collections and edema were seen in the remaining cases. Several studies have evaluated the usefulness of US in addition to mammography in cases of focal, noncyclical breast pain and concluded that in the setting of a negative mammogram, US may not be indicated, especially in patients with nondense breasts. A retrospective study of 206 patients with focal breast pain as their only symptom evaluated with US after a mammogram found that US resulted in 8 additional biopsies and 14 additional 6-month follow-up examinations without detecting any additional cancers [11]. Another retrospective study found 76 imaging abnormalities in 413 cases of focal pain, with 46 (61%) seen on US alone, for a specificity of 82%. While there were no malignancies, US found a benign lesion in 40 of 56 cases in which mammography was negative in patients with dense breasts and found a benign lesion in 6 of 20 cases with a negative mammogram and nondense breasts. | Breast Pain. Additionally, Tumyan et al [38] in a retrospective study of mammography in combination with US found a NPV of 100%, though the study was limited by a significant number of patients being lost to follow-up. DBT DBT While there is no literature specifically evaluating the use of DBT in the workup of focal and noncyclical breast pain, DBT can be useful in the diagnostic setting. It is known to improve lesion characterization in noncalcified lesions and cancer detection when compared to conventional mammographic workup [28-30,39-41]. US Breast While there are few studies evaluating US independently of mammography in the setting of focal and noncyclical breast pain, the existing literature suggests that US may be useful to exclude malignancy in these cases. A retrospective review of 110 cases of focal breast pain evaluated by US found no imaging abnormality in 85 cases (77.3%) [12] and there were no malignancies. In 15 cases (13.6%), cysts were identified, and 3 patients (2.7%) had solid masses, all of which were benign. Fluid collections and edema were seen in the remaining cases. Several studies have evaluated the usefulness of US in addition to mammography in cases of focal, noncyclical breast pain and concluded that in the setting of a negative mammogram, US may not be indicated, especially in patients with nondense breasts. A retrospective study of 206 patients with focal breast pain as their only symptom evaluated with US after a mammogram found that US resulted in 8 additional biopsies and 14 additional 6-month follow-up examinations without detecting any additional cancers [11]. Another retrospective study found 76 imaging abnormalities in 413 cases of focal pain, with 46 (61%) seen on US alone, for a specificity of 82%. While there were no malignancies, US found a benign lesion in 40 of 56 cases in which mammography was negative in patients with dense breasts and found a benign lesion in 6 of 20 cases with a negative mammogram and nondense breasts. | 3091546 |
acrac_3091546_6 | Breast Pain | The specificity of US was 95% for nondense breasts and 87% for dense breasts [9]. Some authors suggest that, despite the low incidence of malignancy, US may be useful in that it could potentially find treatable causes of breast pain, such as cysts [9]. On the other hand, a prospective, observational follow-up study of 987 patients with breast pain alone found benign findings in 8.6% of cases, which consisted mostly of small cysts [14]. The authors argued that in the absence of a palpable abnormality, any cyst that may be found by US would be unlikely to be large enough to cause pain or benefit from aspiration. MRI Breast MRI Breast There is no relevant literature regarding the use of MRI in the evaluation of focal and noncyclical breast pain. Sestamibi MBI Sestamibi MBI There is no relevant literature regarding the use of MBI in the evaluation of focal and noncyclical breast pain. Variant 4: Female with clinically significant breast pain (focal and noncyclical). Age greater than or equal to 40. Initial imaging. Mammography Though the incidence is low, mammography may be used to exclude malignancy in cases of focal and noncyclical breast pain. Mammography was found to have a high sensitivity (100%) and NPV (100%) in a retrospective review of 206 patients with focal breast pain [11]. While this study found specificity to be slightly lower at Breast Pain 87.6%, another retrospective study of focal, noncyclical pain calculated a specificity of mammography of 97% for nondense breasts and 96% for dense breasts [9]. Additionally, Tumyan et al [38] in a retrospective study of mammography in combination with US found a NPV of 100%, though the study was limited by a significant number of patients being lost to follow-up. A mammogram should be obtained if the patient has not undergone mammography within the last 3 to 6 months. | Breast Pain. The specificity of US was 95% for nondense breasts and 87% for dense breasts [9]. Some authors suggest that, despite the low incidence of malignancy, US may be useful in that it could potentially find treatable causes of breast pain, such as cysts [9]. On the other hand, a prospective, observational follow-up study of 987 patients with breast pain alone found benign findings in 8.6% of cases, which consisted mostly of small cysts [14]. The authors argued that in the absence of a palpable abnormality, any cyst that may be found by US would be unlikely to be large enough to cause pain or benefit from aspiration. MRI Breast MRI Breast There is no relevant literature regarding the use of MRI in the evaluation of focal and noncyclical breast pain. Sestamibi MBI Sestamibi MBI There is no relevant literature regarding the use of MBI in the evaluation of focal and noncyclical breast pain. Variant 4: Female with clinically significant breast pain (focal and noncyclical). Age greater than or equal to 40. Initial imaging. Mammography Though the incidence is low, mammography may be used to exclude malignancy in cases of focal and noncyclical breast pain. Mammography was found to have a high sensitivity (100%) and NPV (100%) in a retrospective review of 206 patients with focal breast pain [11]. While this study found specificity to be slightly lower at Breast Pain 87.6%, another retrospective study of focal, noncyclical pain calculated a specificity of mammography of 97% for nondense breasts and 96% for dense breasts [9]. Additionally, Tumyan et al [38] in a retrospective study of mammography in combination with US found a NPV of 100%, though the study was limited by a significant number of patients being lost to follow-up. A mammogram should be obtained if the patient has not undergone mammography within the last 3 to 6 months. | 3091546 |
acrac_3091546_7 | Breast Pain | DBT DBT While there is no literature specifically evaluating the use of DBT in the workup of focal and noncyclical breast pain, DBT can be useful in the diagnostic setting and is known to improve lesion characterization in noncalcified lesions when compared to conventional mammographic workup [28-30]. US Breast While there are few studies evaluating US independently of mammography in the setting of focal and noncyclical breast pain, the existing literature suggests that US may be useful to exclude malignancy in these cases. A retrospective review of 110 cases of focal breast pain evaluated by US found no imaging abnormality in 85 cases (77.3%) [12], and there were no malignancies. In 15 cases (13.6%), cysts were identified, and of those, 3 patients (2.7%) had solid masses, all of which were benign. Fluid collections and edema were seen in the remaining cases. Several studies have evaluated the usefulness of US in addition to mammography in cases of focal, noncyclical breast pain and concluded that in the setting of a negative mammogram, US may not be indicated, especially in patients with nondense breasts. A retrospective study of 206 patients with focal breast pain as their only symptom evaluated with US after a mammogram, found that US resulted in 8 additional biopsies and 14 additional 6-month follow-up examinations without detecting any additional cancers [11]. Another retrospective study found 76 imaging abnormalities in 413 cases of focal pain, with 46 (61%) seen on US alone, for a specificity of 82%. While there were no malignancies, US found a benign lesion in 40 of 56 cases in which mammography was negative in patients with dense breasts and found a benign lesion in 6 of 20 cases with a negative mammogram and nondense breasts. The specificity of US was 95% for nondense breasts and 87% for dense breasts [9]. Some authors suggest that, despite the low incidence of malignancy, US may be useful in that it could potentially find treatable causes of breast pain, such as cysts [9]. | Breast Pain. DBT DBT While there is no literature specifically evaluating the use of DBT in the workup of focal and noncyclical breast pain, DBT can be useful in the diagnostic setting and is known to improve lesion characterization in noncalcified lesions when compared to conventional mammographic workup [28-30]. US Breast While there are few studies evaluating US independently of mammography in the setting of focal and noncyclical breast pain, the existing literature suggests that US may be useful to exclude malignancy in these cases. A retrospective review of 110 cases of focal breast pain evaluated by US found no imaging abnormality in 85 cases (77.3%) [12], and there were no malignancies. In 15 cases (13.6%), cysts were identified, and of those, 3 patients (2.7%) had solid masses, all of which were benign. Fluid collections and edema were seen in the remaining cases. Several studies have evaluated the usefulness of US in addition to mammography in cases of focal, noncyclical breast pain and concluded that in the setting of a negative mammogram, US may not be indicated, especially in patients with nondense breasts. A retrospective study of 206 patients with focal breast pain as their only symptom evaluated with US after a mammogram, found that US resulted in 8 additional biopsies and 14 additional 6-month follow-up examinations without detecting any additional cancers [11]. Another retrospective study found 76 imaging abnormalities in 413 cases of focal pain, with 46 (61%) seen on US alone, for a specificity of 82%. While there were no malignancies, US found a benign lesion in 40 of 56 cases in which mammography was negative in patients with dense breasts and found a benign lesion in 6 of 20 cases with a negative mammogram and nondense breasts. The specificity of US was 95% for nondense breasts and 87% for dense breasts [9]. Some authors suggest that, despite the low incidence of malignancy, US may be useful in that it could potentially find treatable causes of breast pain, such as cysts [9]. | 3091546 |
acrac_3158167_0 | Abnormal Liver Function Tests | Introduction/Background Liver function tests are often obtained as part of standard laboratory panels in asymptomatic and symptomatic patients. Alteration in the biochemical markers of hepatocyte damage or bile flow indicate hepatobiliary insult rather than a measurement of liver function. Routine liver chemistries include alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and bilirubin. On the contrary, albumin and prothrombin time are actual markers of hepatocellular synthetic function. The severity of abnormal aminotransferase can be classified as 1) mild: <5 times the upper reference limit, 2) moderate: 5 to 10 times the upper reference limit, or 3) severe: >10 times the upper reference limit. Moderate and severe are discussed collectively as significant clinical overlap exists between these 2 categories. Pathologically increased levels of ALP may occur in cholestatic liver disease, which can show elevated ALP with or without elevated bilirubin. Cholestasis can be due to obstruction of biliary outflow or impairment in bilirubin uptake. If abnormal ALP levels are seen without impairment of other liver enzymes, the etiology is suspected to be cholestatic in origin. If ALP is elevated in isolation, a confirmation with gamma-glutamyl transpeptidase (GGT) or fractionated ALP isoenzyme helps to differentiate hepatic from nonhepatic etiologies, such as bone disease. GGT can be elevated in nonhepatic diseases such as myocardial infarction, renal failure, diabetes, pulmonary, and pancreatic disorders; therefore, it is not used in isolation to assess for liver disease when other liver function tests are normal [1]. Bilirubin is produced by the breakdown of heme. Following conjugation within the liver to increase water solubility, bilirubin is excreted into bile. Conjugated (direct) bilirubin is rapidly excreted in the alimentary tract; thus, bilirubin amounts are negligible in serum in healthy individuals. | Abnormal Liver Function Tests. Introduction/Background Liver function tests are often obtained as part of standard laboratory panels in asymptomatic and symptomatic patients. Alteration in the biochemical markers of hepatocyte damage or bile flow indicate hepatobiliary insult rather than a measurement of liver function. Routine liver chemistries include alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and bilirubin. On the contrary, albumin and prothrombin time are actual markers of hepatocellular synthetic function. The severity of abnormal aminotransferase can be classified as 1) mild: <5 times the upper reference limit, 2) moderate: 5 to 10 times the upper reference limit, or 3) severe: >10 times the upper reference limit. Moderate and severe are discussed collectively as significant clinical overlap exists between these 2 categories. Pathologically increased levels of ALP may occur in cholestatic liver disease, which can show elevated ALP with or without elevated bilirubin. Cholestasis can be due to obstruction of biliary outflow or impairment in bilirubin uptake. If abnormal ALP levels are seen without impairment of other liver enzymes, the etiology is suspected to be cholestatic in origin. If ALP is elevated in isolation, a confirmation with gamma-glutamyl transpeptidase (GGT) or fractionated ALP isoenzyme helps to differentiate hepatic from nonhepatic etiologies, such as bone disease. GGT can be elevated in nonhepatic diseases such as myocardial infarction, renal failure, diabetes, pulmonary, and pancreatic disorders; therefore, it is not used in isolation to assess for liver disease when other liver function tests are normal [1]. Bilirubin is produced by the breakdown of heme. Following conjugation within the liver to increase water solubility, bilirubin is excreted into bile. Conjugated (direct) bilirubin is rapidly excreted in the alimentary tract; thus, bilirubin amounts are negligible in serum in healthy individuals. | 3158167 |
acrac_3158167_1 | Abnormal Liver Function Tests | A rise in levels of conjugated bilirubin in the serum is an indicator of impaired liver excretion. Conjugated hyperbilirubinemia can occur because of impaired bilirubin transport into the intrahepatic bile ducts or downstream obstruction of the biliary tract from intrinsic or extrinsic causes. aUniversity of Arizona, Banner University Medical Center, Tucson, Arizona. bUniversity of Alabama Medical Center, Birmingham, Alabama. cPanel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. dDuke University Medical Center, Durham, North Carolina. eOregon Health & Science University, Portland, Oregon. fPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases. gUniversity of Alabama at Birmingham, Birmingham, Alabama, Primary care physician. hUniversity of Connecticut, Farmington, Connecticut. iUniversity of Alabama at Birmingham Medical Center, Birmingham, Alabama. jJohns Hopkins Bayview Medical Center, Baltimore, Maryland; Commission on Nuclear Medicine and Molecular Imaging. kNorthShore University HealthSystem, Evanston, Illinois. lNew York University Langone Medical Center, New York, New York. mUniversity of Cincinnati Medical Center, Cincinnati, Ohio. nCleveland Clinic, Cleveland, Ohio; American College of Physicians, Hospital Medicine. oJohns Hopkins Hospital, Baltimore, Maryland. pSpecialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia. 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] Abnormal Liver Function Tests | Abnormal Liver Function Tests. A rise in levels of conjugated bilirubin in the serum is an indicator of impaired liver excretion. Conjugated hyperbilirubinemia can occur because of impaired bilirubin transport into the intrahepatic bile ducts or downstream obstruction of the biliary tract from intrinsic or extrinsic causes. aUniversity of Arizona, Banner University Medical Center, Tucson, Arizona. bUniversity of Alabama Medical Center, Birmingham, Alabama. cPanel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. dDuke University Medical Center, Durham, North Carolina. eOregon Health & Science University, Portland, Oregon. fPerelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases. gUniversity of Alabama at Birmingham, Birmingham, Alabama, Primary care physician. hUniversity of Connecticut, Farmington, Connecticut. iUniversity of Alabama at Birmingham Medical Center, Birmingham, Alabama. jJohns Hopkins Bayview Medical Center, Baltimore, Maryland; Commission on Nuclear Medicine and Molecular Imaging. kNorthShore University HealthSystem, Evanston, Illinois. lNew York University Langone Medical Center, New York, New York. mUniversity of Cincinnati Medical Center, Cincinnati, Ohio. nCleveland Clinic, Cleveland, Ohio; American College of Physicians, Hospital Medicine. oJohns Hopkins Hospital, Baltimore, Maryland. pSpecialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia. 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] Abnormal Liver Function Tests | 3158167 |
acrac_3158167_2 | Abnormal Liver Function Tests | Serum unconjugated (indirect) bilirubin can be increased in hemolysis or Gilbert syndrome, which is diagnosed when unconjugated hyperbilirubinemia is the only abnormal liver function test and conjugated bilirubin and complete blood count are normal. OR Discussion of Procedures by Variant Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging. Hepatocellular predominant liver chemistry is seen when aminotransferases are elevated much higher than ALP (cholestatic-pattern). Hepatocellular injury causes the release of ALT and AST in serum. Increase in ALT (mild or moderate to severe) is directly linked to hepatocyte injury. In addition to fatty liver disease, other causes of rising ALT include acute or chronic viral hepatitis, acute Budd-Chiari syndrome, ischemic hepatitis, autoimmune, hemochromatosis, medications/toxins, autoimmune, alpha1-antitrypsin deficiency, and Wilson disease. AST levels are also increased in fatty liver disease and cirrhosis. However, if the aminotransferase rise is predominantly AST, nonhepatic causes (hemolysis, myopathy, thyroid disease, exercise) should also be considered. Common causes of mild increases in aminotransferases are nonalcoholic fatty liver disease (NAFLD) and alcohol- induced liver disease; uncommon causes include drug-induced liver injury, hepatitis B, hepatitis C, and hereditary hemochromatosis. Rare causes are alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. The 2 most common causes of fatty liver disease are NAFLD and alcohol-induced steatosis/steatohepatitis. Excessive intake of alcohol results in alcohol-induced fatty liver disease. The AST:ALT ratio is generally >2 in alcohol-induced fatty liver disease and <1 in metabolic disease-related fatty liver. Alcohol-induced liver disease is caused by excess alcohol consumption, whereas the nonalcoholic variant is related to insulin resistance and the metabolic syndrome. | Abnormal Liver Function Tests. Serum unconjugated (indirect) bilirubin can be increased in hemolysis or Gilbert syndrome, which is diagnosed when unconjugated hyperbilirubinemia is the only abnormal liver function test and conjugated bilirubin and complete blood count are normal. OR Discussion of Procedures by Variant Variant 1: Abnormal liver function tests. Hepatocellular predominance with mild aminotransferase increase. Initial imaging. Hepatocellular predominant liver chemistry is seen when aminotransferases are elevated much higher than ALP (cholestatic-pattern). Hepatocellular injury causes the release of ALT and AST in serum. Increase in ALT (mild or moderate to severe) is directly linked to hepatocyte injury. In addition to fatty liver disease, other causes of rising ALT include acute or chronic viral hepatitis, acute Budd-Chiari syndrome, ischemic hepatitis, autoimmune, hemochromatosis, medications/toxins, autoimmune, alpha1-antitrypsin deficiency, and Wilson disease. AST levels are also increased in fatty liver disease and cirrhosis. However, if the aminotransferase rise is predominantly AST, nonhepatic causes (hemolysis, myopathy, thyroid disease, exercise) should also be considered. Common causes of mild increases in aminotransferases are nonalcoholic fatty liver disease (NAFLD) and alcohol- induced liver disease; uncommon causes include drug-induced liver injury, hepatitis B, hepatitis C, and hereditary hemochromatosis. Rare causes are alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. The 2 most common causes of fatty liver disease are NAFLD and alcohol-induced steatosis/steatohepatitis. Excessive intake of alcohol results in alcohol-induced fatty liver disease. The AST:ALT ratio is generally >2 in alcohol-induced fatty liver disease and <1 in metabolic disease-related fatty liver. Alcohol-induced liver disease is caused by excess alcohol consumption, whereas the nonalcoholic variant is related to insulin resistance and the metabolic syndrome. | 3158167 |
acrac_3158167_3 | Abnormal Liver Function Tests | NAFLD is the most common liver disease in first world countries, with a prevalence of 20% to 30% in the general population; however, this increases to 70% with obesity and 90% with diabetes mellitus. NAFLD is a spectrum of fat deposition and hepatic inflammation followed by fibrosis due to metabolic insults. Simple hepatic steatosis can be seen in 70% to 75% of cases without cellular insult. Nonalcoholic steatohepatitis (NASH) can be found in 25% to 30% of cases with hepatocyte injury and inflammation due to lipid; these entities, simple hepatic steatosis and NASH, can coexist. Progressive insults with inflammation can result in fibrosis leading to cirrhosis and hepatocellular carcinoma [4,5]. US Abdomen Ultrasound (US) is useful as a first-line investigation tool for mild increase in liver enzymes. US has been used world-wide to screen for both alcohol-induced liver disease and NAFLD. US has the benefit of being noninvasive and is an accurate method to detect steatosis [6,7]. US can be successfully diagnose hepatic lipid content of >33% but can be unreliable with mild fatty infiltration, with an 84.8% sensitivity and a 93.6% specificity with US in moderate and sever hepatic fat deposition (defined as >30% by histology) [8,9]. Both sensitivity and specificity declined to 53.3% to 65% and 77% to 81.2%, respectively, when mild steatosis was included with moderate and severe degrees of steatosis. It is noteworthy that sonographic specificity further deteriorates with confounding factors such as inflammation or fibrosis within the liver parenchyma [8,10,11]. Estimation of hepatic steatosis on conventional US is subjective and challenged by inter- and intraobserver variability. Normal liver shows echogenicity similar to or just higher than normal renal cortex. Fatty infiltration Abnormal Liver Function Tests increases the echogenicity of the liver parenchyma. | Abnormal Liver Function Tests. NAFLD is the most common liver disease in first world countries, with a prevalence of 20% to 30% in the general population; however, this increases to 70% with obesity and 90% with diabetes mellitus. NAFLD is a spectrum of fat deposition and hepatic inflammation followed by fibrosis due to metabolic insults. Simple hepatic steatosis can be seen in 70% to 75% of cases without cellular insult. Nonalcoholic steatohepatitis (NASH) can be found in 25% to 30% of cases with hepatocyte injury and inflammation due to lipid; these entities, simple hepatic steatosis and NASH, can coexist. Progressive insults with inflammation can result in fibrosis leading to cirrhosis and hepatocellular carcinoma [4,5]. US Abdomen Ultrasound (US) is useful as a first-line investigation tool for mild increase in liver enzymes. US has been used world-wide to screen for both alcohol-induced liver disease and NAFLD. US has the benefit of being noninvasive and is an accurate method to detect steatosis [6,7]. US can be successfully diagnose hepatic lipid content of >33% but can be unreliable with mild fatty infiltration, with an 84.8% sensitivity and a 93.6% specificity with US in moderate and sever hepatic fat deposition (defined as >30% by histology) [8,9]. Both sensitivity and specificity declined to 53.3% to 65% and 77% to 81.2%, respectively, when mild steatosis was included with moderate and severe degrees of steatosis. It is noteworthy that sonographic specificity further deteriorates with confounding factors such as inflammation or fibrosis within the liver parenchyma [8,10,11]. Estimation of hepatic steatosis on conventional US is subjective and challenged by inter- and intraobserver variability. Normal liver shows echogenicity similar to or just higher than normal renal cortex. Fatty infiltration Abnormal Liver Function Tests increases the echogenicity of the liver parenchyma. | 3158167 |
acrac_3158167_4 | Abnormal Liver Function Tests | Hepatic steatosis can be graded as mild, moderate, and severe: 1) mild: mild diffuse increase in liver echogenicity and clear definition of the diaphragm and intrahepatic vessel walls; 2) moderate: mild diffuse increase in liver echogenicity and obscuration of the diaphragm and intrahepatic vessel walls; and 3) severe: marked increase in liver echogenicity leading to nonvisualization of diaphragm and intrahepatic vessel walls [12]. Instead of qualitative assessment of liver and kidney parenchyma, quantitative grading can be done to obtain hepatorenal index. Mancini et al and Webb et al have shown an excellent correlation of mild steatosis quantified on hepatorenal index to fat fraction on MR spectroscopy and liver biopsy, with the area under the curve measuring up to 99.2% and 99.6%, respectively. The hepatorenal index is independent of confounding factors including high body mass index, inflammation, or fibrosis [13,14]. US Abdomen with IV Contrast Cocciolillo et al [15] showed hepatic blood flow derangements in the portal vein and liver parenchyma using contrast-enhanced US (CEUS). The percentage of maximal contrast activity, regional blood volume (cubic centimeters) and regional blood flow (cubic centimeters per second) was reduced in NASH and NAFLD compared with controls. CEUS can be added to conventional US and US shear wave elastography; however, there is no evidence in the current literature to support the use of CEUS in this clinical scenario. US Duplex Doppler Abdomen Duplex Doppler may be added as adjunct to conventional US B-mode images. The normal triphasic flow pattern in right hepatic vein flow may become monophasic following intrahepatic fat deposition or, occasionally, by inflammatory or fibrotic changes [16]. Tarzamni et al [17] found an increase in the arterial resistive index and no change in pulsatility index and portal venous velocity in patients with NAFLD with favorable response to treatment. | Abnormal Liver Function Tests. Hepatic steatosis can be graded as mild, moderate, and severe: 1) mild: mild diffuse increase in liver echogenicity and clear definition of the diaphragm and intrahepatic vessel walls; 2) moderate: mild diffuse increase in liver echogenicity and obscuration of the diaphragm and intrahepatic vessel walls; and 3) severe: marked increase in liver echogenicity leading to nonvisualization of diaphragm and intrahepatic vessel walls [12]. Instead of qualitative assessment of liver and kidney parenchyma, quantitative grading can be done to obtain hepatorenal index. Mancini et al and Webb et al have shown an excellent correlation of mild steatosis quantified on hepatorenal index to fat fraction on MR spectroscopy and liver biopsy, with the area under the curve measuring up to 99.2% and 99.6%, respectively. The hepatorenal index is independent of confounding factors including high body mass index, inflammation, or fibrosis [13,14]. US Abdomen with IV Contrast Cocciolillo et al [15] showed hepatic blood flow derangements in the portal vein and liver parenchyma using contrast-enhanced US (CEUS). The percentage of maximal contrast activity, regional blood volume (cubic centimeters) and regional blood flow (cubic centimeters per second) was reduced in NASH and NAFLD compared with controls. CEUS can be added to conventional US and US shear wave elastography; however, there is no evidence in the current literature to support the use of CEUS in this clinical scenario. US Duplex Doppler Abdomen Duplex Doppler may be added as adjunct to conventional US B-mode images. The normal triphasic flow pattern in right hepatic vein flow may become monophasic following intrahepatic fat deposition or, occasionally, by inflammatory or fibrotic changes [16]. Tarzamni et al [17] found an increase in the arterial resistive index and no change in pulsatility index and portal venous velocity in patients with NAFLD with favorable response to treatment. | 3158167 |
acrac_3158167_5 | Abnormal Liver Function Tests | US Shear Wave Elastography Abdomen US shear wave elastography is increasingly used to assess liver stiffness in chronic liver parenchymal disease. Various US elastography techniques have evolved in recent years that use different shear wave generation and propagation. These include transient elastography, acoustic radiation force impulse elastography, supersonic shear wave, and real-time tissue elastography. Controlled attenuation parameter is a novel method for the measurement of hepatic steatosis that uses the same radiofrequency data used for quantification of liver stiffness. Shi at al [18] performed a meta-analysis to look at performance of controlled attenuation parameter in detection of severity of steatosis (>S1, >S2, >S3). The sensitivity and specificity were 78% and 79% for S1, 85% and 79% for S2 and, 83% and 79% for S3 steatosis, respectively. Receiver operating characteristic analysis was 85% for >S1, 88% for >S2, and 87% for >S3. According to the meta- analysis, controlled attenuation parameter has a good sensitivity and specificity for detecting hepatic fat content; however, accuracy is limited. However, CT is not useful as the first modality of choice for the diagnosis of mildly elevated aminotransferases due to mild fatty infiltration for multiple reasons, including failure to detect early steatosis, lack of accuracy, and reliability [20,23,24]. Abnormal Liver Function Tests CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature to support the use of CT abdomen and pelvis without and with IV contrast in this clinical scenario. MR Elastography Abdomen MR elastography is the most useful modality to estimate liver fibrosis. MR elastography is currently being investigated to diagnose NAFLD without liver fibrosis and therefore is not an initial investigation. | Abnormal Liver Function Tests. US Shear Wave Elastography Abdomen US shear wave elastography is increasingly used to assess liver stiffness in chronic liver parenchymal disease. Various US elastography techniques have evolved in recent years that use different shear wave generation and propagation. These include transient elastography, acoustic radiation force impulse elastography, supersonic shear wave, and real-time tissue elastography. Controlled attenuation parameter is a novel method for the measurement of hepatic steatosis that uses the same radiofrequency data used for quantification of liver stiffness. Shi at al [18] performed a meta-analysis to look at performance of controlled attenuation parameter in detection of severity of steatosis (>S1, >S2, >S3). The sensitivity and specificity were 78% and 79% for S1, 85% and 79% for S2 and, 83% and 79% for S3 steatosis, respectively. Receiver operating characteristic analysis was 85% for >S1, 88% for >S2, and 87% for >S3. According to the meta- analysis, controlled attenuation parameter has a good sensitivity and specificity for detecting hepatic fat content; however, accuracy is limited. However, CT is not useful as the first modality of choice for the diagnosis of mildly elevated aminotransferases due to mild fatty infiltration for multiple reasons, including failure to detect early steatosis, lack of accuracy, and reliability [20,23,24]. Abnormal Liver Function Tests CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature to support the use of CT abdomen and pelvis without and with IV contrast in this clinical scenario. MR Elastography Abdomen MR elastography is the most useful modality to estimate liver fibrosis. MR elastography is currently being investigated to diagnose NAFLD without liver fibrosis and therefore is not an initial investigation. | 3158167 |
acrac_3158167_6 | Abnormal Liver Function Tests | Chen et al [27] showed higher liver stiffness in patients with steatosis and lobular inflammation than in those with steatosis and lower stiffness when compared with those with parenchymal fibrosis in fatty liver. Chemical shift imaging using T1 gradient echo exploits the differences in the resonance frequencies of water and fat proton signals yielding 2-point Dixon T1 in-phase and opposed-phase with fat and iron depiction. However, T2* decay from hepatic iron can erroneously lead to an underestimation of liver fat content by reducing in-phase signal, particularly at longer time to echo [28-31]. Proton density fat fraction is a quantitative and reproducible method for fat estimation that uses chemical shift while eliminating or reducing the effects of confounding factors, such as T2 decay. Proton density fat fraction is an accurate (area under the receiver operating characteristic curve = 98.9%; 95% confidence interval, 96.8%-100%) and reliable tool for hepatic lipid assessment (grade 1 or higher) across different vendors and magnetic field strengths. Recent investigations suggest that quantitative MR methods may serve as a comparable or even better reference standard for fat quantification to reference standard liver biopsy [32,33]. MRI Abdomen Without and With IV Contrast With MRCP There is no relevant literature to support the use of MRI abdomen without and with IV contrast with MR cholangiopancreatography (MRCP) in this clinical scenario. Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging. Breu et al [34], in a large multicenter study, found ischemic hepatitis to be the most common cause for markedly elevated aminotransferase ALT/AST level (5000 IU/L). Ischemic liver injury is a serious condition because it can progress to liver failure and high mortality [35]. | Abnormal Liver Function Tests. Chen et al [27] showed higher liver stiffness in patients with steatosis and lobular inflammation than in those with steatosis and lower stiffness when compared with those with parenchymal fibrosis in fatty liver. Chemical shift imaging using T1 gradient echo exploits the differences in the resonance frequencies of water and fat proton signals yielding 2-point Dixon T1 in-phase and opposed-phase with fat and iron depiction. However, T2* decay from hepatic iron can erroneously lead to an underestimation of liver fat content by reducing in-phase signal, particularly at longer time to echo [28-31]. Proton density fat fraction is a quantitative and reproducible method for fat estimation that uses chemical shift while eliminating or reducing the effects of confounding factors, such as T2 decay. Proton density fat fraction is an accurate (area under the receiver operating characteristic curve = 98.9%; 95% confidence interval, 96.8%-100%) and reliable tool for hepatic lipid assessment (grade 1 or higher) across different vendors and magnetic field strengths. Recent investigations suggest that quantitative MR methods may serve as a comparable or even better reference standard for fat quantification to reference standard liver biopsy [32,33]. MRI Abdomen Without and With IV Contrast With MRCP There is no relevant literature to support the use of MRI abdomen without and with IV contrast with MR cholangiopancreatography (MRCP) in this clinical scenario. Variant 2: Abnormal liver function tests. Hepatocellular predominance with moderate or severe aminotransferase increase. Initial imaging. Breu et al [34], in a large multicenter study, found ischemic hepatitis to be the most common cause for markedly elevated aminotransferase ALT/AST level (5000 IU/L). Ischemic liver injury is a serious condition because it can progress to liver failure and high mortality [35]. | 3158167 |
acrac_3158167_7 | Abnormal Liver Function Tests | Acute viral hepatitis (hepatitis A and B, hepatitis C), drug-induced liver injury (acetaminophen), and pancreaticobiliary pathologies leading to biliary obstruction and liver injury are other causes of moderate to marked increase in aminotransferases [34]. CT Abdomen and Pelvis Without IV Contrast Although intra- and extrahepatic biliary ductal dilatation may be identified on CT abdomen and pelvis without IV contrast, contrast confers added benefit for assessment of ischemic liver injury and possible useful hemodynamic information, such as sequela of portal hypertension or hepatic congestion. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites, pelvic collateral vessels in portal hypertension, and possible sources of obstruction (eg, lymphadenopathy). CT Abdomen and Pelvis With IV Contrast Although the findings of acute hepatitis on CT are not specific for the diagnosis, CT may be useful for evaluating the sequela or complications of hepatitis. CT with IV contrast can also identify ischemic hepatitis. Acute hepatitis on contrast-enhanced CT demonstrates arterial heterogeneity, periportal hypoattenuation, perihepatic lymphadenopathy (>7 mm), and ascites in decreasing order of prevalence [37]. A thickened gallbladder Abnormal Liver Function Tests wall on contrast-enhanced CT (mean 5.2 mm) was an independent predictor of severe hepatitis and prolonged cholestasis [37]. An association of enhanced CT findings with phases of acute hepatitis (prodrome, jaundice, recovery) showed small hepatoduodenal lymphadenopathy, perihepatic fat infiltration, gallbladder wall thickening, contraction, or an undulating inner margin, periportal edema, hepatomegaly, splenomegaly, and pelvic fluid collection in 98.8%, 76.5%, 75.3%, 43.5%, 22.4%, 52.9%, and 56.5% of the patients, respectively [38,39]. | Abnormal Liver Function Tests. Acute viral hepatitis (hepatitis A and B, hepatitis C), drug-induced liver injury (acetaminophen), and pancreaticobiliary pathologies leading to biliary obstruction and liver injury are other causes of moderate to marked increase in aminotransferases [34]. CT Abdomen and Pelvis Without IV Contrast Although intra- and extrahepatic biliary ductal dilatation may be identified on CT abdomen and pelvis without IV contrast, contrast confers added benefit for assessment of ischemic liver injury and possible useful hemodynamic information, such as sequela of portal hypertension or hepatic congestion. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites, pelvic collateral vessels in portal hypertension, and possible sources of obstruction (eg, lymphadenopathy). CT Abdomen and Pelvis With IV Contrast Although the findings of acute hepatitis on CT are not specific for the diagnosis, CT may be useful for evaluating the sequela or complications of hepatitis. CT with IV contrast can also identify ischemic hepatitis. Acute hepatitis on contrast-enhanced CT demonstrates arterial heterogeneity, periportal hypoattenuation, perihepatic lymphadenopathy (>7 mm), and ascites in decreasing order of prevalence [37]. A thickened gallbladder Abnormal Liver Function Tests wall on contrast-enhanced CT (mean 5.2 mm) was an independent predictor of severe hepatitis and prolonged cholestasis [37]. An association of enhanced CT findings with phases of acute hepatitis (prodrome, jaundice, recovery) showed small hepatoduodenal lymphadenopathy, perihepatic fat infiltration, gallbladder wall thickening, contraction, or an undulating inner margin, periportal edema, hepatomegaly, splenomegaly, and pelvic fluid collection in 98.8%, 76.5%, 75.3%, 43.5%, 22.4%, 52.9%, and 56.5% of the patients, respectively [38,39]. | 3158167 |
acrac_3158167_8 | Abnormal Liver Function Tests | Shock liver, leading to ischemic hepatitis, may be secondary to systemic hypoxic or hypotensive causes leading to hypoperfusion of the liver, which may show hypoenhancement of a portion of the liver or entire liver parenchyma. Selective hepatic hypoperfusion due to hepatic arterial of portal venous occlusion could be reversible because of dual blood supply but may result in liver failure or hepatic infarction [40]. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites as well as collateral vessels in instances of portal venous hypertension. CT Abdomen and Pelvis Without and With IV Contrast CT of the abdomen and pelvis with and without IV contrast is not typically useful for this clinical scenario because there is no benefit from adding unenhanced images. MR Elastography Abdomen Currently there is no role for MR elastography to diagnose acute hepatic inflammation from various causes. Superimposed acute inflammation in chronic viral hepatitis does not impact correlation of stiffness with stage of fibrosis [41,42]. MRI Abdomen with MRCP Although abdominal US is the preferred modality of choice in severely elevated aminotransferase, MRI with IV contrast can be obtained to assess parenchymal inflammation, perfusion, and vascular patency. Inflamed liver parenchyma shows increased signal intensity on T2-weighted images and decreased signal on T1- weighted images with heterogeneous perfusion, similar to CT. Periportal edema can be appreciated as a hyperintense signal on T2-weighted images. Heterogeneous enhancement of the liver in the arterial phase is seen in acute hepatic inflammation from various causes [43-48]. Perihepatic fluid and gallbladder wall edema can be seen on T2-weighted images in acute hepatitis. Hepatic capsular edema may be present in fulminant hepatitis with resultant heterogeneous enhancement on postgadolinium T1- weighted images. | Abnormal Liver Function Tests. Shock liver, leading to ischemic hepatitis, may be secondary to systemic hypoxic or hypotensive causes leading to hypoperfusion of the liver, which may show hypoenhancement of a portion of the liver or entire liver parenchyma. Selective hepatic hypoperfusion due to hepatic arterial of portal venous occlusion could be reversible because of dual blood supply but may result in liver failure or hepatic infarction [40]. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites as well as collateral vessels in instances of portal venous hypertension. CT Abdomen and Pelvis Without and With IV Contrast CT of the abdomen and pelvis with and without IV contrast is not typically useful for this clinical scenario because there is no benefit from adding unenhanced images. MR Elastography Abdomen Currently there is no role for MR elastography to diagnose acute hepatic inflammation from various causes. Superimposed acute inflammation in chronic viral hepatitis does not impact correlation of stiffness with stage of fibrosis [41,42]. MRI Abdomen with MRCP Although abdominal US is the preferred modality of choice in severely elevated aminotransferase, MRI with IV contrast can be obtained to assess parenchymal inflammation, perfusion, and vascular patency. Inflamed liver parenchyma shows increased signal intensity on T2-weighted images and decreased signal on T1- weighted images with heterogeneous perfusion, similar to CT. Periportal edema can be appreciated as a hyperintense signal on T2-weighted images. Heterogeneous enhancement of the liver in the arterial phase is seen in acute hepatic inflammation from various causes [43-48]. Perihepatic fluid and gallbladder wall edema can be seen on T2-weighted images in acute hepatitis. Hepatic capsular edema may be present in fulminant hepatitis with resultant heterogeneous enhancement on postgadolinium T1- weighted images. | 3158167 |
acrac_3158167_9 | Abnormal Liver Function Tests | Hepatic infarction is seen as nonenhancing wedge-shaped hepatic parenchyma. Vascular cause for ischemic hepatitis can be identified on postcontrast imaging, including MR angiogram [38,49]. Several investigations have shown impaired uptake of liver-specific agents in hepatic dysfunction. Gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid is a paramagnetic hepatobiliary MR contrast agent, which (due to its OATP1B1/B3-dependent hepatocyte-specific uptake and paramagnetic properties) is used for evaluation of liver function analysis [50-53]. US Abdomen with IV Contrast CEUS is not a first-line imaging modality to assess the hepatic parenchyma in acute severe hepatitis or ischemia. Investigations to use as adjunct to check vascular patency in transplant livers has been tried [60], but there is a lack of relevant literature to support the use of CEUS in this clinical scenario. Abnormal Liver Function Tests US Duplex Doppler Abdomen Duplex Doppler can be added to routine grayscale US to look for vascular patency in patients with suspected ischemic insult. US Shear Wave Elastography Abdomen There is no relevant literature to support the use of US shear wave elastography in toxic or ischemic liver injury. Choledocholithiasis is the most common cause of extrahepatic biliary obstruction and elevated ALP of liver origin. Additional etiologies of extrahepatic biliary obstruction include malignant obstruction, biliary strictures, and infections (eg, AIDS cholangiopathy, and liver flukes). Isolated elevated ALP of hepatic origin (without other elevated liver function tests) that persists over time suggests a chronic cholestatic process, such as partial bile duct obstruction, primary biliary cholangitis, primary sclerosing cholangitis, or drug-induced cholestasis. Infiltrative liver diseases such as sarcoidosis, amyloidosis, and hepatic metastases, among others, may also lead to intrahepatic cholestasis. | Abnormal Liver Function Tests. Hepatic infarction is seen as nonenhancing wedge-shaped hepatic parenchyma. Vascular cause for ischemic hepatitis can be identified on postcontrast imaging, including MR angiogram [38,49]. Several investigations have shown impaired uptake of liver-specific agents in hepatic dysfunction. Gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid is a paramagnetic hepatobiliary MR contrast agent, which (due to its OATP1B1/B3-dependent hepatocyte-specific uptake and paramagnetic properties) is used for evaluation of liver function analysis [50-53]. US Abdomen with IV Contrast CEUS is not a first-line imaging modality to assess the hepatic parenchyma in acute severe hepatitis or ischemia. Investigations to use as adjunct to check vascular patency in transplant livers has been tried [60], but there is a lack of relevant literature to support the use of CEUS in this clinical scenario. Abnormal Liver Function Tests US Duplex Doppler Abdomen Duplex Doppler can be added to routine grayscale US to look for vascular patency in patients with suspected ischemic insult. US Shear Wave Elastography Abdomen There is no relevant literature to support the use of US shear wave elastography in toxic or ischemic liver injury. Choledocholithiasis is the most common cause of extrahepatic biliary obstruction and elevated ALP of liver origin. Additional etiologies of extrahepatic biliary obstruction include malignant obstruction, biliary strictures, and infections (eg, AIDS cholangiopathy, and liver flukes). Isolated elevated ALP of hepatic origin (without other elevated liver function tests) that persists over time suggests a chronic cholestatic process, such as partial bile duct obstruction, primary biliary cholangitis, primary sclerosing cholangitis, or drug-induced cholestasis. Infiltrative liver diseases such as sarcoidosis, amyloidosis, and hepatic metastases, among others, may also lead to intrahepatic cholestasis. | 3158167 |
acrac_3158167_10 | Abnormal Liver Function Tests | ALP may also be elevated nonspecifically in addition to other elevated liver biochemical tests in all types of liver diseases, including hepatitis, cirrhosis, sepsis, and heart failure. CT Abdomen and Pelvis With IV Contrast Although abdominal US is typically the first-line imaging modality for identifying biliary obstruction, contrast- enhanced CT of the abdomen and pelvis may help define the site of obstruction, potential etiology, and coexistent complications [63]. CT is considered less sensitive than MRI with MRCP for the evaluation of the bile ducts; however, CT may provide useful information regarding the etiology of cholestasis. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites, pelvic collateral vessels in portal hypertension, and possible sources of obstruction (eg, lymphadenopathy). CT Abdomen and Pelvis Without and With IV Contrast CT of the abdomen and pelvis with and without IV contrast is not typically performed for this clinical scenario because there is no benefit from adding unenhanced images. CT Abdomen and Pelvis Without IV Contrast Although intra- and extrahepatic biliary ductal dilatation may be identified on CT abdomen and pelvis without IV contrast, contrast confers added benefit for assessment of ischemic liver injury and possible useful hemodynamic information, such as sequela of portal hypertension or hepatic congestion. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites, pelvic collateral vessels in portal hypertension, and possible sources of obstruction (eg, lymphadenopathy). MR Elastography Abdomen MR elastography is currently the most accurate imaging modality for the diagnosis and staging of hepatic fibrosis; however, it has a limited to no role in the initial imaging of suspected cholestasis. Abnormal Liver Function Tests | Abnormal Liver Function Tests. ALP may also be elevated nonspecifically in addition to other elevated liver biochemical tests in all types of liver diseases, including hepatitis, cirrhosis, sepsis, and heart failure. CT Abdomen and Pelvis With IV Contrast Although abdominal US is typically the first-line imaging modality for identifying biliary obstruction, contrast- enhanced CT of the abdomen and pelvis may help define the site of obstruction, potential etiology, and coexistent complications [63]. CT is considered less sensitive than MRI with MRCP for the evaluation of the bile ducts; however, CT may provide useful information regarding the etiology of cholestasis. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites, pelvic collateral vessels in portal hypertension, and possible sources of obstruction (eg, lymphadenopathy). CT Abdomen and Pelvis Without and With IV Contrast CT of the abdomen and pelvis with and without IV contrast is not typically performed for this clinical scenario because there is no benefit from adding unenhanced images. CT Abdomen and Pelvis Without IV Contrast Although intra- and extrahepatic biliary ductal dilatation may be identified on CT abdomen and pelvis without IV contrast, contrast confers added benefit for assessment of ischemic liver injury and possible useful hemodynamic information, such as sequela of portal hypertension or hepatic congestion. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting pelvic ascites, pelvic collateral vessels in portal hypertension, and possible sources of obstruction (eg, lymphadenopathy). MR Elastography Abdomen MR elastography is currently the most accurate imaging modality for the diagnosis and staging of hepatic fibrosis; however, it has a limited to no role in the initial imaging of suspected cholestasis. Abnormal Liver Function Tests | 3158167 |
acrac_3158167_11 | Abnormal Liver Function Tests | MRI Abdomen Without and With IV Contrast With MRCP Abdominal US is typically the first-line imaging modality; however, in the setting of persistently elevated ALP and a negative abdominal sonogram, MRI abdomen without and with IV contrast with MRCP may be useful. Sustained elevation of ALP is significantly correlated with choledocholithiasis on MRCP and may be helpful for triaging patients to endoscopic retrograde cholangiopancreatography (ERCP); however, patients who have common bile duct stones demonstrated on US should proceed directly to ERCP [64,65]. If extra- or intrahepatic biliary ductal dilatation is identified on abdominal US, contrast-enhanced MRI with MRCP is the most useful imaging modality for evaluating the etiology of biliary obstruction. Contrast-enhanced MRI with MRCP facilitates noninvasive evaluation of both intra- and extrahepatic bile ducts, as well as the liver parenchyma [66]. Further, contrast-enhanced MRI with MRCP enables triaging of patients to subsequent interventions, such as stenting with ERCP, brushings by endoscopic US, and image-guided or laparoscopic biopsy, as well as serving as a guide for the subsequent approach with these interventions. MRI performed with diffusion sequences and hepatobiliary contrast agents can be advantageous in lesion detection and characterization, although a decreased uptake of hepatobiliary agents by hepatocytes might decrease diagnostic accuracy, especially in patients with reduced liver function [51]. MRI Abdomen Without IV Contrast With MRCP Although less sensitive than contrast-enhanced MRI, a noncontrast MRI (including MRCP) may be useful for identifying biliary obstruction as a source of cholestasis. Contrast administration improves the sensitivity for detection of acute cholangitis, hepatic metastases, and the detection of primary sclerosing cholangitis. | Abnormal Liver Function Tests. MRI Abdomen Without and With IV Contrast With MRCP Abdominal US is typically the first-line imaging modality; however, in the setting of persistently elevated ALP and a negative abdominal sonogram, MRI abdomen without and with IV contrast with MRCP may be useful. Sustained elevation of ALP is significantly correlated with choledocholithiasis on MRCP and may be helpful for triaging patients to endoscopic retrograde cholangiopancreatography (ERCP); however, patients who have common bile duct stones demonstrated on US should proceed directly to ERCP [64,65]. If extra- or intrahepatic biliary ductal dilatation is identified on abdominal US, contrast-enhanced MRI with MRCP is the most useful imaging modality for evaluating the etiology of biliary obstruction. Contrast-enhanced MRI with MRCP facilitates noninvasive evaluation of both intra- and extrahepatic bile ducts, as well as the liver parenchyma [66]. Further, contrast-enhanced MRI with MRCP enables triaging of patients to subsequent interventions, such as stenting with ERCP, brushings by endoscopic US, and image-guided or laparoscopic biopsy, as well as serving as a guide for the subsequent approach with these interventions. MRI performed with diffusion sequences and hepatobiliary contrast agents can be advantageous in lesion detection and characterization, although a decreased uptake of hepatobiliary agents by hepatocytes might decrease diagnostic accuracy, especially in patients with reduced liver function [51]. MRI Abdomen Without IV Contrast With MRCP Although less sensitive than contrast-enhanced MRI, a noncontrast MRI (including MRCP) may be useful for identifying biliary obstruction as a source of cholestasis. Contrast administration improves the sensitivity for detection of acute cholangitis, hepatic metastases, and the detection of primary sclerosing cholangitis. | 3158167 |
acrac_3158167_12 | Abnormal Liver Function Tests | Furthermore, excretion of hepatobiliary contrast and opacification of the biliary ducts and gallbladder provide additional information regarding the site and etiology of obstruction, as well as liver function [67-69]. US Abdomen Patients with elevated ALP suspected to be liver in origin and no alternative etiology should undergo transabdominal US to assess for dilated intra- or extrahepatic ducts and gallstones as the possible cause. Gallstone disease is prevalent with approximately 10% of adults having cholelithiasis and approximately 500,000 cholecystectomy operations performed annually [70]. Approximately 18% of adults undergoing cholecystectomy have choledocholithiasis [71,72]. Although abdominal US has a low sensitivity for detection of choledocholithiasis, in part related to frequent overlying bowel gas, it has high specificity [65]. When biliary obstruction is identified on abdominal US, frequently dynamic contrast-enhanced CT, MRI, or CEUS is required for further evaluation of the cause and possibly procedure planning. The absence of gallstones or choledocholithiasis suggests a nongallstone etiology and a normal caliber of the extrahepatic bile duct suggests intrahepatic cholestasis [71-73]. US Abdomen with IV Contrast For initial imaging, there is currently no role for CEUS in the evaluation of cholestasis. CEUS has been assessed for the evaluation of liver fibrosis, which may nonspecifically elevate ALP, and is used in the characterization of potentially obstructing hepatic lesions. Similar to CT and MRI perfusion techniques, CEUS uses contrast media transit characteristics to make deductions about liver hemodynamics that relate to the presence and severity of liver fibrosis and for the characterization of hepatic lesions. US Duplex Doppler Abdomen There is debate regarding the diagnostic value of adding Doppler US to the US abdomen examination for initial imaging. | Abnormal Liver Function Tests. Furthermore, excretion of hepatobiliary contrast and opacification of the biliary ducts and gallbladder provide additional information regarding the site and etiology of obstruction, as well as liver function [67-69]. US Abdomen Patients with elevated ALP suspected to be liver in origin and no alternative etiology should undergo transabdominal US to assess for dilated intra- or extrahepatic ducts and gallstones as the possible cause. Gallstone disease is prevalent with approximately 10% of adults having cholelithiasis and approximately 500,000 cholecystectomy operations performed annually [70]. Approximately 18% of adults undergoing cholecystectomy have choledocholithiasis [71,72]. Although abdominal US has a low sensitivity for detection of choledocholithiasis, in part related to frequent overlying bowel gas, it has high specificity [65]. When biliary obstruction is identified on abdominal US, frequently dynamic contrast-enhanced CT, MRI, or CEUS is required for further evaluation of the cause and possibly procedure planning. The absence of gallstones or choledocholithiasis suggests a nongallstone etiology and a normal caliber of the extrahepatic bile duct suggests intrahepatic cholestasis [71-73]. US Abdomen with IV Contrast For initial imaging, there is currently no role for CEUS in the evaluation of cholestasis. CEUS has been assessed for the evaluation of liver fibrosis, which may nonspecifically elevate ALP, and is used in the characterization of potentially obstructing hepatic lesions. Similar to CT and MRI perfusion techniques, CEUS uses contrast media transit characteristics to make deductions about liver hemodynamics that relate to the presence and severity of liver fibrosis and for the characterization of hepatic lesions. US Duplex Doppler Abdomen There is debate regarding the diagnostic value of adding Doppler US to the US abdomen examination for initial imaging. | 3158167 |
acrac_3158167_13 | Abnormal Liver Function Tests | Doppler US can demonstrate hemodynamic alterations related to infection (such as elevated velocity in the main hepatic artery in acute cholecystitis) or indicative of portal hypertension as seen in fibrosis or infiltrative liver diseases. The diagnostic value of Doppler US of the portal vein for the evaluation of liver function is still controversial [74]. US Shear Wave Elastography Abdomen There is no relevant literature to support the use of US shear wave elastography in the evaluation of cholestasis. US shear wave elastography is used to assess for evaluation of liver fibrosis, which may nonspecifically elevate ALP; however, it has a limited to no role in the initial imaging of suspected cholestasis. US Abdomen US is the most useful imaging modality to evaluate conjugated hyperbilirubinemia due to liver parenchymal cause (alcoholic or viral hepatitis and cirrhosis) or biliary obstruction. US shows a positive predictive value of 98% and a sensitivity in the range of 65% to 95% for the diagnosis of liver parenchymal disease. Biliary obstruction can be demonstrated on US with a wide range of sensitivity (32%-100%) and specificity (71%-97%); however, the cause for distal obstruction may be obscured by overlying bowel gas [54]. US Abdomen with IV Contrast There is no relevant literature to support the use of CEUS in this clinical scenario. caxuda US Duplex Doppler Abdomen US duplex Doppler abdomen is not useful for this clinical scenario. US Shear Wave Elastography Abdomen US shear wave elastography is not useful as the first-line imaging modality to assess hyperbilirubinemia. Liver fibrosis can be demonstrated using elastography techniques with improved accuracy in higher stages of fibrosis (area under the curve, 0.88 and 0.91 for S2 and S4 fibrosis, respectively) [18]. There is no evidence to support use of US shear wave elastography in biliary obstruction. | Abnormal Liver Function Tests. Doppler US can demonstrate hemodynamic alterations related to infection (such as elevated velocity in the main hepatic artery in acute cholecystitis) or indicative of portal hypertension as seen in fibrosis or infiltrative liver diseases. The diagnostic value of Doppler US of the portal vein for the evaluation of liver function is still controversial [74]. US Shear Wave Elastography Abdomen There is no relevant literature to support the use of US shear wave elastography in the evaluation of cholestasis. US shear wave elastography is used to assess for evaluation of liver fibrosis, which may nonspecifically elevate ALP; however, it has a limited to no role in the initial imaging of suspected cholestasis. US Abdomen US is the most useful imaging modality to evaluate conjugated hyperbilirubinemia due to liver parenchymal cause (alcoholic or viral hepatitis and cirrhosis) or biliary obstruction. US shows a positive predictive value of 98% and a sensitivity in the range of 65% to 95% for the diagnosis of liver parenchymal disease. Biliary obstruction can be demonstrated on US with a wide range of sensitivity (32%-100%) and specificity (71%-97%); however, the cause for distal obstruction may be obscured by overlying bowel gas [54]. US Abdomen with IV Contrast There is no relevant literature to support the use of CEUS in this clinical scenario. caxuda US Duplex Doppler Abdomen US duplex Doppler abdomen is not useful for this clinical scenario. US Shear Wave Elastography Abdomen US shear wave elastography is not useful as the first-line imaging modality to assess hyperbilirubinemia. Liver fibrosis can be demonstrated using elastography techniques with improved accuracy in higher stages of fibrosis (area under the curve, 0.88 and 0.91 for S2 and S4 fibrosis, respectively) [18]. There is no evidence to support use of US shear wave elastography in biliary obstruction. | 3158167 |
acrac_3158167_14 | Abnormal Liver Function Tests | CT Abdomen and Pelvis With IV Contrast CT abdomen with IV contrast can be used to look for morphologic changes of chronic liver parenchymal disease and its complications. CT can help identify the site of obstruction and the potential etiologies. MRI with MRCP is superior to evaluate the biliary system. Malignant biliary strictures can be identified with a high sensitivity (95%), specificity (93.35%), and accuracy (88.5%) on CT [79]. Abnormal Liver Function Tests CT abdomen with IV contrast is very accurate for diagnosis and staging of pancreaticobiliary malignancies, which can present with hyperbilirubinemia. Tumor resectability and surgical planning for both pancreatic and biliary cancers can be done using CT. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting lymphadenopathy and pelvic ascites. CT Abdomen and Pelvis Without and With IV Contrast CT of the abdomen and pelvis with and without IV contrast is not typically useful for this clinical scenario because there is no benefit from adding unenhanced images. CT Abdomen and Pelvis Without IV Contrast Unenhanced CT has limited utility in assessing biliary obstruction (including etiologies) and liver fibrosis. MRI Abdomen with MRCP As discussed in Variant 3 above, MRI with MRCP is the most useful for evaluating the etiology of biliary obstruction. Contrast is helpful to look for cholangitis and assess malignant etiologies of biliary obstruction. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Abnormal Liver Function Tests 12 2. | Abnormal Liver Function Tests. CT Abdomen and Pelvis With IV Contrast CT abdomen with IV contrast can be used to look for morphologic changes of chronic liver parenchymal disease and its complications. CT can help identify the site of obstruction and the potential etiologies. MRI with MRCP is superior to evaluate the biliary system. Malignant biliary strictures can be identified with a high sensitivity (95%), specificity (93.35%), and accuracy (88.5%) on CT [79]. Abnormal Liver Function Tests CT abdomen with IV contrast is very accurate for diagnosis and staging of pancreaticobiliary malignancies, which can present with hyperbilirubinemia. Tumor resectability and surgical planning for both pancreatic and biliary cancers can be done using CT. There are advantages to including the pelvis in the CT abdomen and pelvis examination, including detecting lymphadenopathy and pelvic ascites. CT Abdomen and Pelvis Without and With IV Contrast CT of the abdomen and pelvis with and without IV contrast is not typically useful for this clinical scenario because there is no benefit from adding unenhanced images. CT Abdomen and Pelvis Without IV Contrast Unenhanced CT has limited utility in assessing biliary obstruction (including etiologies) and liver fibrosis. MRI Abdomen with MRCP As discussed in Variant 3 above, MRI with MRCP is the most useful for evaluating the etiology of biliary obstruction. Contrast is helpful to look for cholangitis and assess malignant etiologies of biliary obstruction. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Abnormal Liver Function Tests 12 2. | 3158167 |
acrac_3158167_15 | Abnormal Liver Function Tests | Neuschwander-Tetri BA, Unalp A, Creer MH, Nonalcoholic Steatohepatitis Clinical Research N. Influence of local reference populations on upper limits of normal for serum alanine aminotransferase levels. Arch Intern Med 2008;168:663-6. 3. Pettersson J, Hindorf U, Persson P, et al. Muscular exercise can cause highly pathological liver function tests in healthy men. Br J Clin Pharmacol 2008;65:253-9. 4. Arshad T, Golabi P, Henry L, Younossi ZM. Epidemiology of Non-alcoholic Fatty Liver Disease in North America. Curr Pharm Des 2020;26:993-97. 5. Cotter TG, Rinella M. Nonalcoholic Fatty Liver Disease 2020: The State of the Disease. Gastroenterology 2020;158:1851-64. 6. Chen CL, Cheng YF, Yu CY, et al. Living donor liver transplantation: the Asian perspective. Transplantation 2014;97 Suppl 8:S3. 7. Singh D, Das CJ, Baruah MP. Imaging of non alcoholic fatty liver disease: A road less travelled. Indian J Endocrinol Metab 2013;17:990-5. 8. Hernaez R, Lazo M, Bonekamp S, et al. Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis. Hepatology 2011;54:1082-90. 9. Saadeh S, Younossi ZM, Remer EM, et al. The utility of radiological imaging in nonalcoholic fatty liver disease. Gastroenterology 2002;123:745-50. 10. Lee SS, Park SH, Kim HJ, et al. Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations. J Hepatol 2010;52:579-85. 11. van Werven JR, Marsman HA, Nederveen AJ, et al. Assessment of hepatic steatosis in patients undergoing liver resection: comparison of US, CT, T1-weighted dual-echo MR imaging, and point-resolved 1H MR spectroscopy. Radiology 2010;256:159-68. 12. Walas MK, Skoczylas K, Gierblinski I. Standards of the Polish Ultrasound Society - update. The liver, gallbladder and bile ducts examinations. J Ultrason 2012;12:428-45. 13. Mancini M, Prinster A, Annuzzi G, et al. | Abnormal Liver Function Tests. Neuschwander-Tetri BA, Unalp A, Creer MH, Nonalcoholic Steatohepatitis Clinical Research N. Influence of local reference populations on upper limits of normal for serum alanine aminotransferase levels. Arch Intern Med 2008;168:663-6. 3. Pettersson J, Hindorf U, Persson P, et al. Muscular exercise can cause highly pathological liver function tests in healthy men. Br J Clin Pharmacol 2008;65:253-9. 4. Arshad T, Golabi P, Henry L, Younossi ZM. Epidemiology of Non-alcoholic Fatty Liver Disease in North America. Curr Pharm Des 2020;26:993-97. 5. Cotter TG, Rinella M. Nonalcoholic Fatty Liver Disease 2020: The State of the Disease. Gastroenterology 2020;158:1851-64. 6. Chen CL, Cheng YF, Yu CY, et al. Living donor liver transplantation: the Asian perspective. Transplantation 2014;97 Suppl 8:S3. 7. Singh D, Das CJ, Baruah MP. Imaging of non alcoholic fatty liver disease: A road less travelled. Indian J Endocrinol Metab 2013;17:990-5. 8. Hernaez R, Lazo M, Bonekamp S, et al. Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: a meta-analysis. Hepatology 2011;54:1082-90. 9. Saadeh S, Younossi ZM, Remer EM, et al. The utility of radiological imaging in nonalcoholic fatty liver disease. Gastroenterology 2002;123:745-50. 10. Lee SS, Park SH, Kim HJ, et al. Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations. J Hepatol 2010;52:579-85. 11. van Werven JR, Marsman HA, Nederveen AJ, et al. Assessment of hepatic steatosis in patients undergoing liver resection: comparison of US, CT, T1-weighted dual-echo MR imaging, and point-resolved 1H MR spectroscopy. Radiology 2010;256:159-68. 12. Walas MK, Skoczylas K, Gierblinski I. Standards of the Polish Ultrasound Society - update. The liver, gallbladder and bile ducts examinations. J Ultrason 2012;12:428-45. 13. Mancini M, Prinster A, Annuzzi G, et al. | 3158167 |
acrac_3158167_16 | Abnormal Liver Function Tests | Sonographic hepatic-renal ratio as indicator of hepatic steatosis: comparison with (1)H magnetic resonance spectroscopy. Metabolism 2009;58:1724-30. 14. Webb M, Yeshua H, Zelber-Sagi S, et al. Diagnostic value of a computerized hepatorenal index for sonographic quantification of liver steatosis. AJR Am J Roentgenol 2009;192:909-14. 15. Cocciolillo S, Parruti G, Marzio L. CEUS and Fibroscan in non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. World J Hepatol 2014;6:496-503. 16. Dietrich CF, Lee JH, Gottschalk R, et al. Hepatic and portal vein flow pattern in correlation with intrahepatic fat deposition and liver histology in patients with chronic hepatitis C. AJR Am J Roentgenol 1998;171:437-43. 17. Tarzamni MK, Khoshbaten M, Sadrarhami S, et al. Hepatic Artery and Portal Vein Doppler Indexes in Non- alcoholic Fatty Liver Disease Before and After Treatment to Prevent Unnecessary Health Care Costs. Int J Prev Med 2014;5:472-7. 18. Shi KQ, Tang JZ, Zhu XL, et al. Controlled attenuation parameter for the detection of steatosis severity in chronic liver disease: a meta-analysis of diagnostic accuracy. J Gastroenterol Hepatol 2014;29:1149-58. 19. Lawrence DA, Oliva IB, Israel GM. Detection of hepatic steatosis on contrast-enhanced CT images: diagnostic accuracy of identification of areas of presumed focal fatty sparing. AJR Am J Roentgenol 2012;199:44-7. 20. Park SH, Kim PN, Kim KW, et al. Macrovesicular hepatic steatosis in living liver donors: use of CT for quantitative and qualitative assessment. Radiology 2006;239:105-12. 21. Kodama Y, Ng CS, Wu TT, et al. Comparison of CT methods for determining the fat content of the liver. AJR Am J Roentgenol 2007;188:1307-12. 22. Ricci C, Longo R, Gioulis E, et al. Noninvasive in vivo quantitative assessment of fat content in human liver. J Hepatol 1997;27:108-13. 23. Birnbaum BA, Hindman N, Lee J, Babb JS. | Abnormal Liver Function Tests. Sonographic hepatic-renal ratio as indicator of hepatic steatosis: comparison with (1)H magnetic resonance spectroscopy. Metabolism 2009;58:1724-30. 14. Webb M, Yeshua H, Zelber-Sagi S, et al. Diagnostic value of a computerized hepatorenal index for sonographic quantification of liver steatosis. AJR Am J Roentgenol 2009;192:909-14. 15. Cocciolillo S, Parruti G, Marzio L. CEUS and Fibroscan in non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. World J Hepatol 2014;6:496-503. 16. Dietrich CF, Lee JH, Gottschalk R, et al. Hepatic and portal vein flow pattern in correlation with intrahepatic fat deposition and liver histology in patients with chronic hepatitis C. AJR Am J Roentgenol 1998;171:437-43. 17. Tarzamni MK, Khoshbaten M, Sadrarhami S, et al. Hepatic Artery and Portal Vein Doppler Indexes in Non- alcoholic Fatty Liver Disease Before and After Treatment to Prevent Unnecessary Health Care Costs. Int J Prev Med 2014;5:472-7. 18. Shi KQ, Tang JZ, Zhu XL, et al. Controlled attenuation parameter for the detection of steatosis severity in chronic liver disease: a meta-analysis of diagnostic accuracy. J Gastroenterol Hepatol 2014;29:1149-58. 19. Lawrence DA, Oliva IB, Israel GM. Detection of hepatic steatosis on contrast-enhanced CT images: diagnostic accuracy of identification of areas of presumed focal fatty sparing. AJR Am J Roentgenol 2012;199:44-7. 20. Park SH, Kim PN, Kim KW, et al. Macrovesicular hepatic steatosis in living liver donors: use of CT for quantitative and qualitative assessment. Radiology 2006;239:105-12. 21. Kodama Y, Ng CS, Wu TT, et al. Comparison of CT methods for determining the fat content of the liver. AJR Am J Roentgenol 2007;188:1307-12. 22. Ricci C, Longo R, Gioulis E, et al. Noninvasive in vivo quantitative assessment of fat content in human liver. J Hepatol 1997;27:108-13. 23. Birnbaum BA, Hindman N, Lee J, Babb JS. | 3158167 |
acrac_69430_0 | Imaging After Total Knee Arthroplasty | Introduction/Background Total knee arthroplasty (TKA), primarily used to treat pain and improve function in patients with symptomatic advanced knee osteoarthritis, is the most commonly performed joint replacement procedure in the United States [1,2]. In 2012, >670,000 knee replacement procedures were performed in the United States [3], which represents an increase of 86% since 2003 [4]. It is estimated that 4 million patients in the United States are currently living with a knee replacement [5]. By 2030, it is estimated that the annual demand for primary TKA will grow by 673% to 3.48 million [6]. Factors contributing to the rising number of TKAs include population growth; aging and increased longevity of the population; expanded indications for performing TKA, especially in individuals >65 years of age; obesity; decline in postprocedure complications; and increased patient demand [7]. Special Imaging Considerations In some patients with knee arthroplasties, repeated hemarthroses are caused by synovial hyperemia or true arteriovenous malformations. These patients can be successfully diagnosed with angiography and treated with embolization. In rare instances, geniculate and popliteal vessel injuries may occur during surgery [15]. A recent study reports single-photon emission CT (SPECT)/CT arthrography with Tc-99m sulfur colloid has a high diagnostic accuracy (97%) in the evaluation of loosening of both hip and knee arthroplasties in patients with persistent postprocedural pain [16]. Barnsley et al [17] also found arthrography with SPECT/CT to be an accurate means of identifying aseptic prosthetic joint loosening. aPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. bPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. cUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. dPenn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania. | Imaging After Total Knee Arthroplasty. Introduction/Background Total knee arthroplasty (TKA), primarily used to treat pain and improve function in patients with symptomatic advanced knee osteoarthritis, is the most commonly performed joint replacement procedure in the United States [1,2]. In 2012, >670,000 knee replacement procedures were performed in the United States [3], which represents an increase of 86% since 2003 [4]. It is estimated that 4 million patients in the United States are currently living with a knee replacement [5]. By 2030, it is estimated that the annual demand for primary TKA will grow by 673% to 3.48 million [6]. Factors contributing to the rising number of TKAs include population growth; aging and increased longevity of the population; expanded indications for performing TKA, especially in individuals >65 years of age; obesity; decline in postprocedure complications; and increased patient demand [7]. Special Imaging Considerations In some patients with knee arthroplasties, repeated hemarthroses are caused by synovial hyperemia or true arteriovenous malformations. These patients can be successfully diagnosed with angiography and treated with embolization. In rare instances, geniculate and popliteal vessel injuries may occur during surgery [15]. A recent study reports single-photon emission CT (SPECT)/CT arthrography with Tc-99m sulfur colloid has a high diagnostic accuracy (97%) in the evaluation of loosening of both hip and knee arthroplasties in patients with persistent postprocedural pain [16]. Barnsley et al [17] also found arthrography with SPECT/CT to be an accurate means of identifying aseptic prosthetic joint loosening. aPenn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland. bPanel Chair, Mayo Clinic Arizona, Phoenix, Arizona. cUniversity of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. dPenn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania. | 69430 |
acrac_69430_1 | Imaging After Total Knee Arthroplasty | eMayo Clinic, Rochester, Minnesota. fEmory University, Atlanta, Georgia; Committee on Emergency Radiology-GSER. gHospital for Special Surgery, New York, New York. hPenn State Health, Hershey, Pennsylvania, Primary care physician. iDuke University Medical Center, Durham, North Carolina. jUniversity of Missouri Health Care, Columbia, Missouri. kSpecialty Chair, University of Kentucky, Lexington, Kentucky. 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] Imaging After Total Knee Arthroplasty OR Discussion of Procedures by Variant Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging. 3-Phase Bone Scan Knee There is insufficient evidence to support the use of 3-phase bone scan for the initial evaluation of TKA. CT Arthrography Knee There is insufficient evidence to support the use of CT arthrography for the initial evaluation of TKA. CT Knee With IV Contrast There is insufficient evidence to support the use of CT with intravenous (IV) contrast for the initial evaluation of TKA. CT Knee Without and With IV Contrast There is insufficient evidence to support the use of CT without and with IV contrast for the initial evaluation of TKA. CT Knee Without IV Contrast There is insufficient evidence to support the use of CT without IV contrast for the initial evaluation of TKA. FDG-PET/CT Whole Body There is insufficient evidence to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT for the initial evaluation of TKA. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the initial evaluation of TKA. | Imaging After Total Knee Arthroplasty. eMayo Clinic, Rochester, Minnesota. fEmory University, Atlanta, Georgia; Committee on Emergency Radiology-GSER. gHospital for Special Surgery, New York, New York. hPenn State Health, Hershey, Pennsylvania, Primary care physician. iDuke University Medical Center, Durham, North Carolina. jUniversity of Missouri Health Care, Columbia, Missouri. kSpecialty Chair, University of Kentucky, Lexington, Kentucky. 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] Imaging After Total Knee Arthroplasty OR Discussion of Procedures by Variant Variant 1: Follow-up of symptomatic or asymptomatic patients with a total knee arthroplasty. Initial imaging. 3-Phase Bone Scan Knee There is insufficient evidence to support the use of 3-phase bone scan for the initial evaluation of TKA. CT Arthrography Knee There is insufficient evidence to support the use of CT arthrography for the initial evaluation of TKA. CT Knee With IV Contrast There is insufficient evidence to support the use of CT with intravenous (IV) contrast for the initial evaluation of TKA. CT Knee Without and With IV Contrast There is insufficient evidence to support the use of CT without and with IV contrast for the initial evaluation of TKA. CT Knee Without IV Contrast There is insufficient evidence to support the use of CT without IV contrast for the initial evaluation of TKA. FDG-PET/CT Whole Body There is insufficient evidence to support the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT for the initial evaluation of TKA. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the initial evaluation of TKA. | 69430 |
acrac_69430_2 | Imaging After Total Knee Arthroplasty | Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the initial evaluation of TKA. Image-Guided Aspiration Knee There is insufficient evidence to support the use of image-guided aspiration for the initial evaluation of TKA. MRI Knee Without and With IV Contrast There is insufficient evidence to support the use of MRI without and with IV contrast for the initial evaluation of TKA. MRI Knee Without IV Contrast There is insufficient evidence to support the use of MRI without IV contrast for the initial evaluation of TKA. Radiography Knee Radiographs can demonstrate abnormal bone and hardware alignment, periprosthetic lucencies and osteolysis [18- 24], reactive bone formation and periostitis, periprosthetic fractures, evidence of polyethylene liner wear, and cement and heterotopic bone about the knee. Radiographs can often delineate effusion, soft-tissue swelling, foreign bodies, soft tissue emphysema, heterotopic bone, and cement or metal in the soft tissues. Radiographs are useful as the initial evaluation for symptomatology or follow-up. Radiographs are often limited in terms of sensitivity, and further imaging may be required. Imaging After Total Knee Arthroplasty Routine immediate postoperative radiographs are considered unnecessary unless the surgery is complicated or there are specific clinical indications warranting imaging evaluation [25,26], because several studies have indicated that the rate of complications identified in the immediate postoperative setting is low. Ververeli et al [27] compared recovery room radiographs with additional predischarge radiographs and found no change in the postoperative management of 124 consecutive patients with TKAs and suggested eliminating the predischarge radiographs. | Imaging After Total Knee Arthroplasty. Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the initial evaluation of TKA. Image-Guided Aspiration Knee There is insufficient evidence to support the use of image-guided aspiration for the initial evaluation of TKA. MRI Knee Without and With IV Contrast There is insufficient evidence to support the use of MRI without and with IV contrast for the initial evaluation of TKA. MRI Knee Without IV Contrast There is insufficient evidence to support the use of MRI without IV contrast for the initial evaluation of TKA. Radiography Knee Radiographs can demonstrate abnormal bone and hardware alignment, periprosthetic lucencies and osteolysis [18- 24], reactive bone formation and periostitis, periprosthetic fractures, evidence of polyethylene liner wear, and cement and heterotopic bone about the knee. Radiographs can often delineate effusion, soft-tissue swelling, foreign bodies, soft tissue emphysema, heterotopic bone, and cement or metal in the soft tissues. Radiographs are useful as the initial evaluation for symptomatology or follow-up. Radiographs are often limited in terms of sensitivity, and further imaging may be required. Imaging After Total Knee Arthroplasty Routine immediate postoperative radiographs are considered unnecessary unless the surgery is complicated or there are specific clinical indications warranting imaging evaluation [25,26], because several studies have indicated that the rate of complications identified in the immediate postoperative setting is low. Ververeli et al [27] compared recovery room radiographs with additional predischarge radiographs and found no change in the postoperative management of 124 consecutive patients with TKAs and suggested eliminating the predischarge radiographs. | 69430 |
acrac_69430_3 | Imaging After Total Knee Arthroplasty | Novack et al [25] retrospectively reviewed 4,830 consecutive patients following cemented or uncemented TKAs and concluded routine recovery room radiographs after an uncomplicated primary TKA are not a reliable mechanism for preventing mechanical complications and did not alter patient care. Radiographic evaluation of wear is based on weightbearing AP and lateral radiographs and on axial radiographs. Liner wear is seen as joint space narrowing, varus or valgus deformity, or patellar tilt. An effusion may be present. Findings can be subtle and annual weightbearing radiographs are suggested for detecting subclinical wear [21]. Collier et al [36] found that 87% of measurements performed on standing frontal knee radiographs (on the basis of the minimum distance from the metallic femoral condyle to a line through the top surface of the baseplate at its widest dimension) were within 1 mm of the known implant thickness, but the accuracy decreased for evaluating polyethylene thickness in patients with wear requiring revision. Instability is evaluated on radiographs obtained in extension-flexion position, under varus-valgus stress, and during anterior and posterior drawer maneuvers. In contrast, malalignment refers to suboptimal alignment of the prosthesis components relative to each other (although it is occasionally used to describe alignment of the bones in relation to each other and to the joint) [37] and is evaluated on full-length standing radiographs of the lower extremity [21]. Radiographs including the entire prosthesis are the initial examination for assessment of suspected periprosthetic fractures. Radiographs are also usually satisfactory for assessment of patellar complications [20] and helpful in guiding treatment [38]. Axial radiographs demonstrate the degree of patellar tilt or subluxation [21]. Baldini et al [39] proposed a weightbearing axial radiograph to better assess patellofemoral kinematics. | Imaging After Total Knee Arthroplasty. Novack et al [25] retrospectively reviewed 4,830 consecutive patients following cemented or uncemented TKAs and concluded routine recovery room radiographs after an uncomplicated primary TKA are not a reliable mechanism for preventing mechanical complications and did not alter patient care. Radiographic evaluation of wear is based on weightbearing AP and lateral radiographs and on axial radiographs. Liner wear is seen as joint space narrowing, varus or valgus deformity, or patellar tilt. An effusion may be present. Findings can be subtle and annual weightbearing radiographs are suggested for detecting subclinical wear [21]. Collier et al [36] found that 87% of measurements performed on standing frontal knee radiographs (on the basis of the minimum distance from the metallic femoral condyle to a line through the top surface of the baseplate at its widest dimension) were within 1 mm of the known implant thickness, but the accuracy decreased for evaluating polyethylene thickness in patients with wear requiring revision. Instability is evaluated on radiographs obtained in extension-flexion position, under varus-valgus stress, and during anterior and posterior drawer maneuvers. In contrast, malalignment refers to suboptimal alignment of the prosthesis components relative to each other (although it is occasionally used to describe alignment of the bones in relation to each other and to the joint) [37] and is evaluated on full-length standing radiographs of the lower extremity [21]. Radiographs including the entire prosthesis are the initial examination for assessment of suspected periprosthetic fractures. Radiographs are also usually satisfactory for assessment of patellar complications [20] and helpful in guiding treatment [38]. Axial radiographs demonstrate the degree of patellar tilt or subluxation [21]. Baldini et al [39] proposed a weightbearing axial radiograph to better assess patellofemoral kinematics. | 69430 |
acrac_69430_4 | Imaging After Total Knee Arthroplasty | Although axial radiographs may be used to determine axial rotation of the femoral component [40], CT is most commonly used for this purpose. Leon-Munoz et al [41] have noted CT-scan-based 3-D models and, therefore, supine CT scan, underestimate the degree of deformity at the knee joint, both in varus and valgus; therefore Imaging After Total Knee Arthroplasty preoperative full-leg standing radiographs should be performed for patient-specific instrumentation assisted TKAs, as a complementary study, to analyze the position of the load-bearing axis. Radiographs cannot directly image post-TKA periprosthetic soft-tissue abnormalities. However, radiographic signs of extensor mechanism tendon tears include patella alta, patella baja, localized soft-tissue swelling, posterior subluxation of the tibia, bony avulsions, and dystrophic calcifications within the tendon [21,42]. US Knee There is insufficient evidence to support the use of ultrasound for the initial evaluation of TKA. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of white blood cell (WBC) scan and sulfur colloid scan for the initial evaluation of TKA. Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs. Infection is a serious complication of joint arthroplasty and is reported in 0.8% to 1.9% of TKAs [43]. The frequency of infection is increasing as the number of primary arthroplasties increases [44]. Infection may be acute or delayed, with delayed infection defined as occurring at least 3 months postoperatively [45]. In a series, infection was responsible for 37.6% of early revisions and 21.9% of revisions performed >2 years after the initial operation [12]. Staphylococcus aureus and coagulase-negative Staphylococcus species, including Staphylococcus epidermidis, are the most common organisms associated with these infections [46]. Both clinical findings and laboratory tests may serve useful in addition to imaging studies. | Imaging After Total Knee Arthroplasty. Although axial radiographs may be used to determine axial rotation of the femoral component [40], CT is most commonly used for this purpose. Leon-Munoz et al [41] have noted CT-scan-based 3-D models and, therefore, supine CT scan, underestimate the degree of deformity at the knee joint, both in varus and valgus; therefore Imaging After Total Knee Arthroplasty preoperative full-leg standing radiographs should be performed for patient-specific instrumentation assisted TKAs, as a complementary study, to analyze the position of the load-bearing axis. Radiographs cannot directly image post-TKA periprosthetic soft-tissue abnormalities. However, radiographic signs of extensor mechanism tendon tears include patella alta, patella baja, localized soft-tissue swelling, posterior subluxation of the tibia, bony avulsions, and dystrophic calcifications within the tendon [21,42]. US Knee There is insufficient evidence to support the use of ultrasound for the initial evaluation of TKA. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of white blood cell (WBC) scan and sulfur colloid scan for the initial evaluation of TKA. Variant 2: Suspected infection after total knee arthroplasty. Additional imaging following radiographs. Infection is a serious complication of joint arthroplasty and is reported in 0.8% to 1.9% of TKAs [43]. The frequency of infection is increasing as the number of primary arthroplasties increases [44]. Infection may be acute or delayed, with delayed infection defined as occurring at least 3 months postoperatively [45]. In a series, infection was responsible for 37.6% of early revisions and 21.9% of revisions performed >2 years after the initial operation [12]. Staphylococcus aureus and coagulase-negative Staphylococcus species, including Staphylococcus epidermidis, are the most common organisms associated with these infections [46]. Both clinical findings and laboratory tests may serve useful in addition to imaging studies. | 69430 |
acrac_69430_5 | Imaging After Total Knee Arthroplasty | Low-grade or chronic TKA infections may be difficult to diagnose preoperatively. Duff et al [18] noted that diagnosis of infection was not obvious in 53% of knees before revision arthroplasty. Pain is the most common presenting symptom of infection, but pain is a nonspecific finding [47]. In acute infection, findings such as pain, swelling, warmth, erythema, and fever are common, whereas chronic infections may be manifested by pain alone [44]. Night pain or pain at rest is characteristic of infection, whereas pain on weightbearing is more characteristic of mechanical loosening. Some authors suggest that infection needs to be excluded in all patients with pain persisting >6 months after joint replacement [18]. Imaging After Total Knee Arthroplasty CT Arthrography Knee CT joint arthrography can assess for lucency with contrast accumulation at the bone/cement/hardware interface. These areas of lucency are not specific for infection versus mechanical loosening. CT Knee With IV Contrast CT has a limited role in the workup of periprosthetic infection. CT with IV contrast could help demonstrate periprosthetic fluid collections and fistulae. Advances in metal artifact reduction may expand the potential role of CT. CT Knee Without and With IV Contrast CT has a limited role in the workup of periprosthetic infection. Noncontrast CT can demonstrate the size and extent of osteolysis, periprosthetic lucencies, intraosseous or soft-tissue gas, and reactive bone formation that might not be evident on radiographs [20,67]. CT with IV contrast could help demonstrate periprosthetic fluid collections and fistulae. Advances in metal artifact reduction may expand the potential role of CT. CT Knee Without IV Contrast CT has a limited role in the workup of periprosthetic infection. Noncontrast CT can demonstrate the size and extent of osteolysis, periprosthetic lucencies, intraosseous or soft-tissue gas, and reactive bone formation that might not be evident on radiographs [20,67]. | Imaging After Total Knee Arthroplasty. Low-grade or chronic TKA infections may be difficult to diagnose preoperatively. Duff et al [18] noted that diagnosis of infection was not obvious in 53% of knees before revision arthroplasty. Pain is the most common presenting symptom of infection, but pain is a nonspecific finding [47]. In acute infection, findings such as pain, swelling, warmth, erythema, and fever are common, whereas chronic infections may be manifested by pain alone [44]. Night pain or pain at rest is characteristic of infection, whereas pain on weightbearing is more characteristic of mechanical loosening. Some authors suggest that infection needs to be excluded in all patients with pain persisting >6 months after joint replacement [18]. Imaging After Total Knee Arthroplasty CT Arthrography Knee CT joint arthrography can assess for lucency with contrast accumulation at the bone/cement/hardware interface. These areas of lucency are not specific for infection versus mechanical loosening. CT Knee With IV Contrast CT has a limited role in the workup of periprosthetic infection. CT with IV contrast could help demonstrate periprosthetic fluid collections and fistulae. Advances in metal artifact reduction may expand the potential role of CT. CT Knee Without and With IV Contrast CT has a limited role in the workup of periprosthetic infection. Noncontrast CT can demonstrate the size and extent of osteolysis, periprosthetic lucencies, intraosseous or soft-tissue gas, and reactive bone formation that might not be evident on radiographs [20,67]. CT with IV contrast could help demonstrate periprosthetic fluid collections and fistulae. Advances in metal artifact reduction may expand the potential role of CT. CT Knee Without IV Contrast CT has a limited role in the workup of periprosthetic infection. Noncontrast CT can demonstrate the size and extent of osteolysis, periprosthetic lucencies, intraosseous or soft-tissue gas, and reactive bone formation that might not be evident on radiographs [20,67]. | 69430 |
acrac_69430_6 | Imaging After Total Knee Arthroplasty | Advances in metal artifact reduction may expand the potential role of CT. FDG-PET/CT Whole Body FDG-PET/CT scans may be useful for detecting infection after joint replacement. FDG-PET images reflect relative levels of glucose uptake and thus reflect the localized level of increased metabolic activity. Zhuang et al [68] reported that elevated glycolytic activity causes inflammatory cells such as neutrophils and activated macrophages to be FDG avid at sites of inflammation and infection. Some periprosthetic uptake may occur because of marrow activity, and adding marrow scanning can increase specificity [69]. In these instances, the marrow study would be performed the next day using a different camera type because the marrow scan relies on lower energy photons (PET, 511keV; Tc-99m, 140 keV). Zhuang et al [68] studied 36 painful knee prostheses using FDG-PET and identified 10 of 11 infected cases but had false-positive results in 7 cases (sensitivity of 90.9%, specificity of 72%, and accuracy of 77.8% for detecting infection). This was a lower accuracy than found in assessment of hip prostheses. The cause for the large number of false-positives was not known. Aksoy et al [70] found a positive predictive value (PPV) of 28% (15 of 54) for infection in 54 patients with painful joint prosthesis (24 knee, 48 hip) using FDG-PET. Manthey et al [71] reported that, by analyzing intensity and periprosthetic uptake patterns on FDG-PET, accurate differentiation among aseptic loosening, synovitis, and infection is possible. Kwee and Kwee [72] reports FDG Imaging After Total Knee Arthroplasty uptake at the bone-prosthesis interface has been consistently reported as diagnostic criterion for knee prosthetic joint infection. Kwee et al [73] in a meta-analysis reported that the specificity of FDG-PET for diagnosing infection was significantly lower for knee prostheses (74.8%) than for hip prostheses (89.8%). | Imaging After Total Knee Arthroplasty. Advances in metal artifact reduction may expand the potential role of CT. FDG-PET/CT Whole Body FDG-PET/CT scans may be useful for detecting infection after joint replacement. FDG-PET images reflect relative levels of glucose uptake and thus reflect the localized level of increased metabolic activity. Zhuang et al [68] reported that elevated glycolytic activity causes inflammatory cells such as neutrophils and activated macrophages to be FDG avid at sites of inflammation and infection. Some periprosthetic uptake may occur because of marrow activity, and adding marrow scanning can increase specificity [69]. In these instances, the marrow study would be performed the next day using a different camera type because the marrow scan relies on lower energy photons (PET, 511keV; Tc-99m, 140 keV). Zhuang et al [68] studied 36 painful knee prostheses using FDG-PET and identified 10 of 11 infected cases but had false-positive results in 7 cases (sensitivity of 90.9%, specificity of 72%, and accuracy of 77.8% for detecting infection). This was a lower accuracy than found in assessment of hip prostheses. The cause for the large number of false-positives was not known. Aksoy et al [70] found a positive predictive value (PPV) of 28% (15 of 54) for infection in 54 patients with painful joint prosthesis (24 knee, 48 hip) using FDG-PET. Manthey et al [71] reported that, by analyzing intensity and periprosthetic uptake patterns on FDG-PET, accurate differentiation among aseptic loosening, synovitis, and infection is possible. Kwee and Kwee [72] reports FDG Imaging After Total Knee Arthroplasty uptake at the bone-prosthesis interface has been consistently reported as diagnostic criterion for knee prosthetic joint infection. Kwee et al [73] in a meta-analysis reported that the specificity of FDG-PET for diagnosing infection was significantly lower for knee prostheses (74.8%) than for hip prostheses (89.8%). | 69430 |
acrac_69430_7 | Imaging After Total Knee Arthroplasty | Delank et al [74], in a series of both hip and knee prostheses, found that a negative PET scan excluded infection (100% sensitivity). If the scan was positive, differentiation between wear and infection was not possible. Prandini et al [75] performed a meta- analysis of the diagnostic performance of different radiotracers in peripheral osteomyelitis and prosthetic joint infections, yielding results for FDG-PET with a sensitivity of 94%, a specificity of 87%, a PPV of 87%, an NPV of 94%, and an overall accuracy of 92%. Although metal artifacts have very little impact on nuclear medicine examinations (except as photopenic defects) and create negligible scatter [68,76,77], high PET attenuation coefficients in the area of metal can lead to an overestimation of the PET activity in that region and thereby to a false-positive PET finding. Nonattenuated PET images, which do not manifest this error, can be used in these cases to aid the interpretation of these metal-induced artifacts. Synovitis and aseptic loosening (in hip prostheses) may cause increased FDG uptake [69]. Sterner et al [78] examined 14 patients with painful TKA to detect early aseptic loosening. Overall accuracy was 71% (sensitivity, 100%; specificity, 56%). In addition, Stumpe et al [79] found diffuse synovial and focal extrasynovial FDG uptake in patients with component malrotation. They concluded that this test is noncontributory in individual patients with persistent pain. Studies in patients with hip prostheses have shown that postoperative remodeling can result in artifactual periprosthetic FDG uptake for up to 6 months after implant insertion [80]. Noting the lack of specificity for detection of periprosthetic infection on conventional FDG-PET, Aksoy et al [70] explored the use of FDG- labeled leukocyte PET/CT for imaging patients with painful joint prostheses and found a sensitivity of 93%, a specificity of 97%, a PPV of 93%, and an NPV of 97%. However, this examination is not in general use. | Imaging After Total Knee Arthroplasty. Delank et al [74], in a series of both hip and knee prostheses, found that a negative PET scan excluded infection (100% sensitivity). If the scan was positive, differentiation between wear and infection was not possible. Prandini et al [75] performed a meta- analysis of the diagnostic performance of different radiotracers in peripheral osteomyelitis and prosthetic joint infections, yielding results for FDG-PET with a sensitivity of 94%, a specificity of 87%, a PPV of 87%, an NPV of 94%, and an overall accuracy of 92%. Although metal artifacts have very little impact on nuclear medicine examinations (except as photopenic defects) and create negligible scatter [68,76,77], high PET attenuation coefficients in the area of metal can lead to an overestimation of the PET activity in that region and thereby to a false-positive PET finding. Nonattenuated PET images, which do not manifest this error, can be used in these cases to aid the interpretation of these metal-induced artifacts. Synovitis and aseptic loosening (in hip prostheses) may cause increased FDG uptake [69]. Sterner et al [78] examined 14 patients with painful TKA to detect early aseptic loosening. Overall accuracy was 71% (sensitivity, 100%; specificity, 56%). In addition, Stumpe et al [79] found diffuse synovial and focal extrasynovial FDG uptake in patients with component malrotation. They concluded that this test is noncontributory in individual patients with persistent pain. Studies in patients with hip prostheses have shown that postoperative remodeling can result in artifactual periprosthetic FDG uptake for up to 6 months after implant insertion [80]. Noting the lack of specificity for detection of periprosthetic infection on conventional FDG-PET, Aksoy et al [70] explored the use of FDG- labeled leukocyte PET/CT for imaging patients with painful joint prostheses and found a sensitivity of 93%, a specificity of 97%, a PPV of 93%, and an NPV of 97%. However, this examination is not in general use. | 69430 |
acrac_69430_8 | Imaging After Total Knee Arthroplasty | Basu et al [81] found the sensitivity, specificity, PPV, and NPV of FDG-PET in knee prostheses were 94.7%, 88.2%, 69.2%, and 98.4%, respectively, in 87 patients with knee prostheses suspected of being either infected or experiencing noninfectious loosening. Van Acker et al [82] investigated the use of FDG-PET in combination with bone scans and showed no advantage over HMPAO-labeled WBC and bone scans. Comparison of FDG-PET with In-111- labeled leukocyte/Tc-99m-labeled sulfur colloid marrow imaging showed that FDG-PET was less accurate than the leukocyte/marrow scans and could not replace that combination of tests [69]. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the initial evaluation of TKA. Imaging After Total Knee Arthroplasty as a month may be necessary for cultures of aspirated fluid to become positive [30]. Weekly repeat aspirations may be needed if the first aspiration is negative and clinical suspicion for infection remains high. Even with a negative preoperative aspiration, intraoperative tissue may indicate infection. Bernard [50], after literature review and a multicenter trial, advocated CRP and joint aspiration as the best tools for diagnosing prosthetic joint infection. When the CRP level is >10 mg/L, repeat joint aspiration or biopsy is suggested. Della Valle [90] also found the combination of ESR and CRP to be a good screening tool for infection, with only one infected knee having negative results on both tests. These authors suggest preoperative aspiration if the ESR or CRP is elevated or if clinical suspicion is high, combined with intraoperative frozen section analysis of the periprosthetic synovial tissue [90]. | Imaging After Total Knee Arthroplasty. Basu et al [81] found the sensitivity, specificity, PPV, and NPV of FDG-PET in knee prostheses were 94.7%, 88.2%, 69.2%, and 98.4%, respectively, in 87 patients with knee prostheses suspected of being either infected or experiencing noninfectious loosening. Van Acker et al [82] investigated the use of FDG-PET in combination with bone scans and showed no advantage over HMPAO-labeled WBC and bone scans. Comparison of FDG-PET with In-111- labeled leukocyte/Tc-99m-labeled sulfur colloid marrow imaging showed that FDG-PET was less accurate than the leukocyte/marrow scans and could not replace that combination of tests [69]. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the initial evaluation of TKA. Imaging After Total Knee Arthroplasty as a month may be necessary for cultures of aspirated fluid to become positive [30]. Weekly repeat aspirations may be needed if the first aspiration is negative and clinical suspicion for infection remains high. Even with a negative preoperative aspiration, intraoperative tissue may indicate infection. Bernard [50], after literature review and a multicenter trial, advocated CRP and joint aspiration as the best tools for diagnosing prosthetic joint infection. When the CRP level is >10 mg/L, repeat joint aspiration or biopsy is suggested. Della Valle [90] also found the combination of ESR and CRP to be a good screening tool for infection, with only one infected knee having negative results on both tests. These authors suggest preoperative aspiration if the ESR or CRP is elevated or if clinical suspicion is high, combined with intraoperative frozen section analysis of the periprosthetic synovial tissue [90]. | 69430 |
acrac_69430_9 | Imaging After Total Knee Arthroplasty | The AAOS gives a moderate strength of recommendation for synovial fluid testing including leukocyte count and neutrophil percentage, aerobic and anaerobic bacterial cultures, leukocyte esterase, alpha-defensin, CRP, and nucleic acid amplification testing (eg, polymerase chain reaction) for bacteria [54]. A recent manuscript advises intraoperative synovial fluid re-cultures are necessary even if the preoperative aspiration culture is positive and any discordance between preoperative aspiration culture and intraoperative synovial fluid culture should be noted [91]. If the joint aspirate culture is positive on the basis of both cell count with differential and positive cultures, then infection is considered likely and treatment is initiated [54,92]. In that setting, no further imaging is supported for the diagnostic workup of the infection. Berbari [46] studied 897 cases of periprosthetic joint infection and found that approximately 7% were associated with negative cultures. If the preoperative synovial cultures remain negative, multiple intraoperative periprosthetic tissues should be submitted for aerobic and anaerobic bacterial culture [54]. MRI Knee Without and With IV Contrast MRI may have a role in the workup of periprosthetic infection. Advances in metal artifact reduction may expand the potential role of MRI. Using metal reduction techniques, Potter and Foo found that infected synovium has hyperintense laminar appearance, distinct from the appearance of particle disease [22,93]. They noted that, in selected cases, MRI may be helpful in detecting extracapsular spread of infection and abscess formation. IV contrast may provide additional benefit in this regard [93]. On the basis of their findings, Plodkowski [94] examined 28 patients with proven infected TKAs and 28 controls with noninfected TKA. | Imaging After Total Knee Arthroplasty. The AAOS gives a moderate strength of recommendation for synovial fluid testing including leukocyte count and neutrophil percentage, aerobic and anaerobic bacterial cultures, leukocyte esterase, alpha-defensin, CRP, and nucleic acid amplification testing (eg, polymerase chain reaction) for bacteria [54]. A recent manuscript advises intraoperative synovial fluid re-cultures are necessary even if the preoperative aspiration culture is positive and any discordance between preoperative aspiration culture and intraoperative synovial fluid culture should be noted [91]. If the joint aspirate culture is positive on the basis of both cell count with differential and positive cultures, then infection is considered likely and treatment is initiated [54,92]. In that setting, no further imaging is supported for the diagnostic workup of the infection. Berbari [46] studied 897 cases of periprosthetic joint infection and found that approximately 7% were associated with negative cultures. If the preoperative synovial cultures remain negative, multiple intraoperative periprosthetic tissues should be submitted for aerobic and anaerobic bacterial culture [54]. MRI Knee Without and With IV Contrast MRI may have a role in the workup of periprosthetic infection. Advances in metal artifact reduction may expand the potential role of MRI. Using metal reduction techniques, Potter and Foo found that infected synovium has hyperintense laminar appearance, distinct from the appearance of particle disease [22,93]. They noted that, in selected cases, MRI may be helpful in detecting extracapsular spread of infection and abscess formation. IV contrast may provide additional benefit in this regard [93]. On the basis of their findings, Plodkowski [94] examined 28 patients with proven infected TKAs and 28 controls with noninfected TKA. | 69430 |
acrac_69430_10 | Imaging After Total Knee Arthroplasty | They found a sensitivity of 86% to 92% and a specificity of 85% to 87%, with almost perfect interobserver agreement, when using the appearance of lamellated hyperintense synovitis to classify infected versus noninfected TKA. Li [95] also reported a different lamellated and hyperintense appearance of the synovium in infected joints, which can be differentiated from frond- like and hypertrophied synovium associated with particle-induced synovitis and from homogeneous fluid-signal intensity effusion associated with a nonspecific synovitis. MRI with metal artifact reduction technique has also been shown to detect osteolysis that is not visible on radiographs [96,97]. Contrast may provide additional benefit in detecting extracapsular spread of infection and abscess formation when compared to noncontrast MRI. MRI Knee Without IV Contrast MRI may have a role in the workup of periprosthetic infection. Advances in metal artifact reduction may expand the potential role of MRI. Using metal reduction techniques, Potter and Foo found that infected synovium has hyperintense laminar appearance, distinct from the appearance of particle disease [22,93]. They noted that, in selected cases, MRI may be helpful in detecting extracapsular spread of infection and abscess formation. Plodkowski et al [94] examined 28 patients with proven infected TKAs and 28 controls with noninfected TKA. They found a sensitivity of 86% to 92% and a specificity of 85% to 87%, with almost perfect interobserver agreement, when using the appearance of lamellated hyperintense synovitis to classify infected versus noninfected TKA. Li et al [95] also reported a different lamellated and hyperintense appearance of the synovium in infected joints, which can be differentiated from frond-like and hypertrophied synovium associated with particle-induced synovitis and from homogeneous fluid-signal intensity effusion associated with a nonspecific synovitis. | Imaging After Total Knee Arthroplasty. They found a sensitivity of 86% to 92% and a specificity of 85% to 87%, with almost perfect interobserver agreement, when using the appearance of lamellated hyperintense synovitis to classify infected versus noninfected TKA. Li [95] also reported a different lamellated and hyperintense appearance of the synovium in infected joints, which can be differentiated from frond- like and hypertrophied synovium associated with particle-induced synovitis and from homogeneous fluid-signal intensity effusion associated with a nonspecific synovitis. MRI with metal artifact reduction technique has also been shown to detect osteolysis that is not visible on radiographs [96,97]. Contrast may provide additional benefit in detecting extracapsular spread of infection and abscess formation when compared to noncontrast MRI. MRI Knee Without IV Contrast MRI may have a role in the workup of periprosthetic infection. Advances in metal artifact reduction may expand the potential role of MRI. Using metal reduction techniques, Potter and Foo found that infected synovium has hyperintense laminar appearance, distinct from the appearance of particle disease [22,93]. They noted that, in selected cases, MRI may be helpful in detecting extracapsular spread of infection and abscess formation. Plodkowski et al [94] examined 28 patients with proven infected TKAs and 28 controls with noninfected TKA. They found a sensitivity of 86% to 92% and a specificity of 85% to 87%, with almost perfect interobserver agreement, when using the appearance of lamellated hyperintense synovitis to classify infected versus noninfected TKA. Li et al [95] also reported a different lamellated and hyperintense appearance of the synovium in infected joints, which can be differentiated from frond-like and hypertrophied synovium associated with particle-induced synovitis and from homogeneous fluid-signal intensity effusion associated with a nonspecific synovitis. | 69430 |
acrac_69430_11 | Imaging After Total Knee Arthroplasty | MRI with metal artifact reduction technique has also been shown to detect osteolysis that is not visible on radiographs [96,97]. US Knee US has a limited role in the workup of periprosthetic infection, but it can be readily used to assess soft tissues, including the presence of edema, hyperemia, and fluid collections about the knee joint in patients with TKA. This may be beneficial in certain situations (eg, practices that may perform fluoroscopy-guided aspiration). Imaging After Total Knee Arthroplasty injection of the radiolabeled WBCs [63]. Comparison of activity on the WBC image with activity on a bone scan (usually a 3-phase bone scan) has been advocated. A positive study for infection generally requires focal increased activity on the WBC study in the same location and distribution as the positive 3-phase bone scan [100]. Using a sequential combination of bone and In-111-labeled leukocyte scans in patients with loose or painful knee prostheses found a sensitivity of 88%, a specificity of 78%, a PPV of 75%, and an NPV of 90% for diagnosis of infection. They noted an area of potential utility for leukocyte scans, specifically that a negative indium leukocyte scan might support the absence of infection in otherwise equivocal cases and in situations in which a musculoskeletal pathologist is not available to interpret an intraoperative frozen section [100]. A small sample of indium scans in uncomplicated postoperative TKA patients has shown that inflammation can persist around the operative site in the absence of infection [100]. Bernard et al [50] reported a multicenter trial of various methods for diagnosing hip and knee infections. Scans using tagged WBCs or radiolabeled immunoglobulin demonstrated a sensitivity of 74% and a specificity of 76% for diagnosing infection. A literature review indicates sensitivities of 40% to 96% and specificities of 76% to 100% for WBC scans of joint prostheses [49,50,99-104]. | Imaging After Total Knee Arthroplasty. MRI with metal artifact reduction technique has also been shown to detect osteolysis that is not visible on radiographs [96,97]. US Knee US has a limited role in the workup of periprosthetic infection, but it can be readily used to assess soft tissues, including the presence of edema, hyperemia, and fluid collections about the knee joint in patients with TKA. This may be beneficial in certain situations (eg, practices that may perform fluoroscopy-guided aspiration). Imaging After Total Knee Arthroplasty injection of the radiolabeled WBCs [63]. Comparison of activity on the WBC image with activity on a bone scan (usually a 3-phase bone scan) has been advocated. A positive study for infection generally requires focal increased activity on the WBC study in the same location and distribution as the positive 3-phase bone scan [100]. Using a sequential combination of bone and In-111-labeled leukocyte scans in patients with loose or painful knee prostheses found a sensitivity of 88%, a specificity of 78%, a PPV of 75%, and an NPV of 90% for diagnosis of infection. They noted an area of potential utility for leukocyte scans, specifically that a negative indium leukocyte scan might support the absence of infection in otherwise equivocal cases and in situations in which a musculoskeletal pathologist is not available to interpret an intraoperative frozen section [100]. A small sample of indium scans in uncomplicated postoperative TKA patients has shown that inflammation can persist around the operative site in the absence of infection [100]. Bernard et al [50] reported a multicenter trial of various methods for diagnosing hip and knee infections. Scans using tagged WBCs or radiolabeled immunoglobulin demonstrated a sensitivity of 74% and a specificity of 76% for diagnosing infection. A literature review indicates sensitivities of 40% to 96% and specificities of 76% to 100% for WBC scans of joint prostheses [49,50,99-104]. | 69430 |
acrac_69430_12 | Imaging After Total Knee Arthroplasty | Therefore, these studies are not useful as routine for differentiating mechanical failure from occult infection in painful loose total knee prostheses. Filippi and Schillaci [105] applied SPECT/CT using a hybrid camera to conventional planar Tc-99m-HMPAO- labeled leukocyte scintigraphy in patients with suspected infection. SPECT/CT was able to differentiate soft-tissue involvement from bone involvement. The authors argued that SPECT/CT might eliminate the necessity for a correlative bone scan with labeled leukocyte scans. WBC scans also have a decreased sensitivity with low-grade infection [66] and a limited neutrophilic component. Labeled leukocyte imaging may lead to a high false-positive rate because leukocytes accumulate in reactive bone marrow as well as in infection and it is not always possible to differentiate between the two [64,106]. The addition of Tc-99m-labeled sulfur colloid bone marrow scanning has been investigated to reduce this confusion. Palestro et al [107] reported that sequential combined leukocyte/marrow imaging was 95% accurate for diagnosing prosthetic knee infection and was superior to bone scans alone or to bone scans in combination with labeled leukocyte imaging. Joseph et al [106] found that low sensitivity and the potential for false-negative results made this combination of scans of limited utility for diagnosing prosthetic infection, and therefore it is no longer used at their institution. In that group of 22 total knee prostheses evaluated and later operated upon, there was a sensitivity of 66%, a specificity of 100%, a PPV of 100%, an NPV of 88%, and an accuracy of 91%. Blanc et al [108] did a retrospective review of 168 patients. They determined Tc-99m-HMPAO labeled leucocyte scintigraphy was more sensitive for knee (84%) than hip prosthesis (57%) but was less specific for knee (52% versus 75%). | Imaging After Total Knee Arthroplasty. Therefore, these studies are not useful as routine for differentiating mechanical failure from occult infection in painful loose total knee prostheses. Filippi and Schillaci [105] applied SPECT/CT using a hybrid camera to conventional planar Tc-99m-HMPAO- labeled leukocyte scintigraphy in patients with suspected infection. SPECT/CT was able to differentiate soft-tissue involvement from bone involvement. The authors argued that SPECT/CT might eliminate the necessity for a correlative bone scan with labeled leukocyte scans. WBC scans also have a decreased sensitivity with low-grade infection [66] and a limited neutrophilic component. Labeled leukocyte imaging may lead to a high false-positive rate because leukocytes accumulate in reactive bone marrow as well as in infection and it is not always possible to differentiate between the two [64,106]. The addition of Tc-99m-labeled sulfur colloid bone marrow scanning has been investigated to reduce this confusion. Palestro et al [107] reported that sequential combined leukocyte/marrow imaging was 95% accurate for diagnosing prosthetic knee infection and was superior to bone scans alone or to bone scans in combination with labeled leukocyte imaging. Joseph et al [106] found that low sensitivity and the potential for false-negative results made this combination of scans of limited utility for diagnosing prosthetic infection, and therefore it is no longer used at their institution. In that group of 22 total knee prostheses evaluated and later operated upon, there was a sensitivity of 66%, a specificity of 100%, a PPV of 100%, an NPV of 88%, and an accuracy of 91%. Blanc et al [108] did a retrospective review of 168 patients. They determined Tc-99m-HMPAO labeled leucocyte scintigraphy was more sensitive for knee (84%) than hip prosthesis (57%) but was less specific for knee (52% versus 75%). | 69430 |
acrac_69430_13 | Imaging After Total Knee Arthroplasty | The addition of blood-pool and flow scans was investigated to determine if hyperemia led to a match of bone marrow-labeled leukocyte uptake (and therefore a false-negative scan). These additional scans decreased the number of false- negative findings (sensitivity, 83%; specificity, 94%; PPV, 83%; NPV, 94%). Overall, the performance of the labeled leukocyte marrow scan protocol was nonetheless thought to be of limited clinical utility [106]. In contrast, Love et al [69] found the combination of In-111-labeled leukocyte/Tc-99m-labeled sulfur colloid marrow scanning to be the reference standard for diagnosing periprosthetic infection. The authors found the combination of labeled WBC and marrow scanning to be 100% sensitive and 100% specific for diagnosing infection in TKA [69]. Semiquantitative assessment of WBC scans using a combination of early and delayed imaging as a substitute for bone marrow imaging produced a >90% sensitivity and specificity in one series [99]. Love et al [109] examined 150 failed joint prostheses with histopathologic correlation and found that leukocyte/marrow imaging yielded a sensitivity of 96%, a specificity of 87%, and an accuracy of 91%. They found that leukocyte/marrow imaging was significantly more accurate than bone scan (50%), bone/gallium scan (66%), and leukocyte/bone imaging (70%) in their population. WBC scan and sulfur colloid scan may have a role in the workup of suspected infection in knee arthroplasty. Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs. Imaging of rotational instability of a TKA is discussed in greater detail under Variant 5. If a patient has undergone a full workup and infection has been excluded, then loosening should be considered as the potential cause of knee pain and periprosthetic lucency. In multiple studies, aseptic loosening has been found to be a common cause of TKA failure [13,110-112]. | Imaging After Total Knee Arthroplasty. The addition of blood-pool and flow scans was investigated to determine if hyperemia led to a match of bone marrow-labeled leukocyte uptake (and therefore a false-negative scan). These additional scans decreased the number of false- negative findings (sensitivity, 83%; specificity, 94%; PPV, 83%; NPV, 94%). Overall, the performance of the labeled leukocyte marrow scan protocol was nonetheless thought to be of limited clinical utility [106]. In contrast, Love et al [69] found the combination of In-111-labeled leukocyte/Tc-99m-labeled sulfur colloid marrow scanning to be the reference standard for diagnosing periprosthetic infection. The authors found the combination of labeled WBC and marrow scanning to be 100% sensitive and 100% specific for diagnosing infection in TKA [69]. Semiquantitative assessment of WBC scans using a combination of early and delayed imaging as a substitute for bone marrow imaging produced a >90% sensitivity and specificity in one series [99]. Love et al [109] examined 150 failed joint prostheses with histopathologic correlation and found that leukocyte/marrow imaging yielded a sensitivity of 96%, a specificity of 87%, and an accuracy of 91%. They found that leukocyte/marrow imaging was significantly more accurate than bone scan (50%), bone/gallium scan (66%), and leukocyte/bone imaging (70%) in their population. WBC scan and sulfur colloid scan may have a role in the workup of suspected infection in knee arthroplasty. Variant 3: Pain after total knee arthroplasty. Infection excluded. Suspect aseptic loosening or osteolysis or instability. Additional imaging following radiographs. Imaging of rotational instability of a TKA is discussed in greater detail under Variant 5. If a patient has undergone a full workup and infection has been excluded, then loosening should be considered as the potential cause of knee pain and periprosthetic lucency. In multiple studies, aseptic loosening has been found to be a common cause of TKA failure [13,110-112]. | 69430 |
acrac_69430_14 | Imaging After Total Knee Arthroplasty | Sharkey et al [13] found aseptic loosening to be the major cause of late stage (>2 years) TKA failure. Aseptic loosening may occur either because of inadequate primary fixation or because of failure after successful fixation. It is thought to result from mechanical stresses, osteolysis secondary to particle debris, or poor bone stock [21]. Loosening may be closely related to other forms of mechanical failure such as osteolysis, Imaging After Total Knee Arthroplasty instability, polyethylene liner wear, and periprosthetic fracture. Osteolysis is a leading cause of late TKA revision. Osteolysis, also known as particle disease and aggressive granulomatosis, occurs secondary to macrophage phagocytosis of particle debris. Debris originating from polyethylene, cement, and metal can all be causes of cell- mediated inflammatory response and osteolysis [113], but typically polyethylene is the most common cause. Areas of osteolysis contain granulation tissue with phagocytosed particulate debris [21]. The incidence of osteolysis is higher for cementless, compared with cemented TKA [114]. Osteolysis can occur anywhere but is more common in the region of the femoral condyles near the attachment of the collateral ligaments, along the periphery of the component, and along the access channels to the cancellous bone of the tibia, including screw holes [114,115]. Patients with osteolysis may be asymptomatic early on but can go on to develop pain, swelling, and acute synovitis. Although small areas of osteolysis may be monitored, the presence of large areas of osteolysis suggest component loosening and may require revision surgery [116]. Imaging can also help evaluate available bone stock in preparation for revision surgery. Instability refers to abnormal and excessive displacement of the articular surfaces of the prosthesis [21]. | Imaging After Total Knee Arthroplasty. Sharkey et al [13] found aseptic loosening to be the major cause of late stage (>2 years) TKA failure. Aseptic loosening may occur either because of inadequate primary fixation or because of failure after successful fixation. It is thought to result from mechanical stresses, osteolysis secondary to particle debris, or poor bone stock [21]. Loosening may be closely related to other forms of mechanical failure such as osteolysis, Imaging After Total Knee Arthroplasty instability, polyethylene liner wear, and periprosthetic fracture. Osteolysis is a leading cause of late TKA revision. Osteolysis, also known as particle disease and aggressive granulomatosis, occurs secondary to macrophage phagocytosis of particle debris. Debris originating from polyethylene, cement, and metal can all be causes of cell- mediated inflammatory response and osteolysis [113], but typically polyethylene is the most common cause. Areas of osteolysis contain granulation tissue with phagocytosed particulate debris [21]. The incidence of osteolysis is higher for cementless, compared with cemented TKA [114]. Osteolysis can occur anywhere but is more common in the region of the femoral condyles near the attachment of the collateral ligaments, along the periphery of the component, and along the access channels to the cancellous bone of the tibia, including screw holes [114,115]. Patients with osteolysis may be asymptomatic early on but can go on to develop pain, swelling, and acute synovitis. Although small areas of osteolysis may be monitored, the presence of large areas of osteolysis suggest component loosening and may require revision surgery [116]. Imaging can also help evaluate available bone stock in preparation for revision surgery. Instability refers to abnormal and excessive displacement of the articular surfaces of the prosthesis [21]. | 69430 |
acrac_69430_15 | Imaging After Total Knee Arthroplasty | Instability usually occurs because of surgical error and/or poor prosthesis selection and often results in revision surgery an average of 4 years after the primary arthroplasty [21]. Severe instability can result in dislocation. In a 2014 review of 781 cases of prosthesis failure, Sharkey et al [12] found that instability represented the third most common cause of prosthesis failure overall, accounting for 7.5% of all cases. The concepts of instability, malalignment, and loosening in TKA are closely interrelated [117]. When malalignment of the joint is created at the time of surgery, minor degrees of instability can become a significant problem. By the same token, instability, ongoing over time, can give rise to malalignment, which, in turn, can lead to loosening. Although ligamentous balance/imbalance plays a role in joint instability, it is not the only factor accounting for stability [118]. 3-Phase Bone Scan Knee There is insufficient evidence to support routine use of Tc-99m 3-phase bone scans for the assessment of instability. CT Arthrography Knee CT joint arthrography can assess for lucency with contrast accumulation at the bone/cement/hardware interface. These areas of lucency are not specific for infection versus mechanical loosening. Imaging After Total Knee Arthroplasty CT Knee With IV Contrast CT with IV contrast is not useful for the assessment of aseptic loosening, osteolysis, or instability. CT Knee Without and With IV Contrast CT without and with IV contrast is not useful for the assessment of aseptic loosening, osteolysis, or instability. CT Knee Without IV Contrast Particularly when metal artifact reduction techniques are used, CT can be used to show the extent and width of lucent zones that may be less apparent on radiographs [20]. MRI and CT have both been shown to be more sensitive for detection of osteolysis than radiographs [116]. | Imaging After Total Knee Arthroplasty. Instability usually occurs because of surgical error and/or poor prosthesis selection and often results in revision surgery an average of 4 years after the primary arthroplasty [21]. Severe instability can result in dislocation. In a 2014 review of 781 cases of prosthesis failure, Sharkey et al [12] found that instability represented the third most common cause of prosthesis failure overall, accounting for 7.5% of all cases. The concepts of instability, malalignment, and loosening in TKA are closely interrelated [117]. When malalignment of the joint is created at the time of surgery, minor degrees of instability can become a significant problem. By the same token, instability, ongoing over time, can give rise to malalignment, which, in turn, can lead to loosening. Although ligamentous balance/imbalance plays a role in joint instability, it is not the only factor accounting for stability [118]. 3-Phase Bone Scan Knee There is insufficient evidence to support routine use of Tc-99m 3-phase bone scans for the assessment of instability. CT Arthrography Knee CT joint arthrography can assess for lucency with contrast accumulation at the bone/cement/hardware interface. These areas of lucency are not specific for infection versus mechanical loosening. Imaging After Total Knee Arthroplasty CT Knee With IV Contrast CT with IV contrast is not useful for the assessment of aseptic loosening, osteolysis, or instability. CT Knee Without and With IV Contrast CT without and with IV contrast is not useful for the assessment of aseptic loosening, osteolysis, or instability. CT Knee Without IV Contrast Particularly when metal artifact reduction techniques are used, CT can be used to show the extent and width of lucent zones that may be less apparent on radiographs [20]. MRI and CT have both been shown to be more sensitive for detection of osteolysis than radiographs [116]. | 69430 |
acrac_69430_16 | Imaging After Total Knee Arthroplasty | CT can be used to detect osteolysis and to determine the total volume of osteolytic lesions, particularly when metal reduction techniques are used [124]. CT is supported by Math et al [20] to look for osteolysis in patients with painful knee prostheses who have normal or equivocal radiographs and increased uptake on all 3 phases of a bone scan. Reish et al [67] found that only 17% of 48 lesions visible by CT were detected on radiographs. They suggested multidetector CT in cases in which osteolysis is expected, such as when there is aseptic loosening and gross polyethylene wear. CT allows the assessment of rotational positioning of the prosthesis components, which can affect patellofemoral tracking and varus/valgus ligamentous stability in flexion [125]. Imaging of rotational instability of a TKA is discussed in greater detail under Variant 5. There are varying reports on FDG sensitivity, specificity, and accuracy, which are likely in part related to nonuniform interpretation criteria and PET techniques. One overall estimate of FDG sensitivity, specificity, and accuracy in TKA is 96%, 77%, and 83%, respectively [126]. Although FDG is reportedly limited in evaluating patients with chronic knee pain after TKA [66,127], further advancements in FDG-PET may potentially be a promising tool in identifying prosthetic osteolysis [126]. Its exact role in the failed joint prosthesis; however, has yet to be determined. There is insufficient evidence to support routine use of FDG-PET/CT for assessment of instability. Fluoride PET/CT Whole Body Koob et al [128] noted a sensitivity of 95.00%, a specificity of 87.04% and an accuracy of 89.19% for the diagnosis of periprosthetic loosening of total hip and knee prosthesis with fluoride PET/CT. There is insufficient evidence to support routine use of fluoride PET/CT for assessment of instability. | Imaging After Total Knee Arthroplasty. CT can be used to detect osteolysis and to determine the total volume of osteolytic lesions, particularly when metal reduction techniques are used [124]. CT is supported by Math et al [20] to look for osteolysis in patients with painful knee prostheses who have normal or equivocal radiographs and increased uptake on all 3 phases of a bone scan. Reish et al [67] found that only 17% of 48 lesions visible by CT were detected on radiographs. They suggested multidetector CT in cases in which osteolysis is expected, such as when there is aseptic loosening and gross polyethylene wear. CT allows the assessment of rotational positioning of the prosthesis components, which can affect patellofemoral tracking and varus/valgus ligamentous stability in flexion [125]. Imaging of rotational instability of a TKA is discussed in greater detail under Variant 5. There are varying reports on FDG sensitivity, specificity, and accuracy, which are likely in part related to nonuniform interpretation criteria and PET techniques. One overall estimate of FDG sensitivity, specificity, and accuracy in TKA is 96%, 77%, and 83%, respectively [126]. Although FDG is reportedly limited in evaluating patients with chronic knee pain after TKA [66,127], further advancements in FDG-PET may potentially be a promising tool in identifying prosthetic osteolysis [126]. Its exact role in the failed joint prosthesis; however, has yet to be determined. There is insufficient evidence to support routine use of FDG-PET/CT for assessment of instability. Fluoride PET/CT Whole Body Koob et al [128] noted a sensitivity of 95.00%, a specificity of 87.04% and an accuracy of 89.19% for the diagnosis of periprosthetic loosening of total hip and knee prosthesis with fluoride PET/CT. There is insufficient evidence to support routine use of fluoride PET/CT for assessment of instability. | 69430 |
acrac_69430_17 | Imaging After Total Knee Arthroplasty | Fluoroscopy Knee There is no recent evidence supporting the routine use of fluoroscopy for the assessment of aseptic loosening, osteolysis, or instability. Fluoroscopy may be useful to see lucent lines in profile that could be obscured on standard AP radiographs [20,129,130] and can also be useful for demonstrating loosening under real-time manipulation. It can be useful in optimally positioning the joint for detection of radiographic osteolysis [129,130] and facilitates dynamic assessment of the knee under stress. In older studies, this procedure was determined to be useful, but it has been supplanted by other modalities and is now infrequently performed. MRI Knee Without and With IV Contrast MRI without and with IV contrast is not useful for assessment of osteolysis or instability. The use of IV contrast for assessing loosening has not been described. Imaging After Total Knee Arthroplasty MRI Knee Without IV Contrast The literature regarding MRI in the detection of implant loosening is evolving, and the available evidence supports its use. Using metal artifact reduction techniques, Fritz et al [93] described what they posited are distinct appearances for an intact periprosthetic interface (direct contact of the implant or cement with the surrounding bone), a periprosthetic fibrous membrane that indicates limited implant fixation that may or may not progress to loosening (1- to 2-mm thick layer with smooth margins surrounding the prosthesis along the bone interface) and frank bone resorption (a periprosthetic layer >2-mm thick with irregular margins). They reserve the use of the term loosening for cases in which MRI demonstrates circumferential osseous resorption together with signs of implant displacement, subsidence, or rotation. In a study of 116 knees in 114 patients that evaluated the interface type (normal, fibrous membrane, fluid, or osteolysis), percent integration (<33%, 33%-66%, or >66%), and presence of bone marrow edema. | Imaging After Total Knee Arthroplasty. Fluoroscopy Knee There is no recent evidence supporting the routine use of fluoroscopy for the assessment of aseptic loosening, osteolysis, or instability. Fluoroscopy may be useful to see lucent lines in profile that could be obscured on standard AP radiographs [20,129,130] and can also be useful for demonstrating loosening under real-time manipulation. It can be useful in optimally positioning the joint for detection of radiographic osteolysis [129,130] and facilitates dynamic assessment of the knee under stress. In older studies, this procedure was determined to be useful, but it has been supplanted by other modalities and is now infrequently performed. MRI Knee Without and With IV Contrast MRI without and with IV contrast is not useful for assessment of osteolysis or instability. The use of IV contrast for assessing loosening has not been described. Imaging After Total Knee Arthroplasty MRI Knee Without IV Contrast The literature regarding MRI in the detection of implant loosening is evolving, and the available evidence supports its use. Using metal artifact reduction techniques, Fritz et al [93] described what they posited are distinct appearances for an intact periprosthetic interface (direct contact of the implant or cement with the surrounding bone), a periprosthetic fibrous membrane that indicates limited implant fixation that may or may not progress to loosening (1- to 2-mm thick layer with smooth margins surrounding the prosthesis along the bone interface) and frank bone resorption (a periprosthetic layer >2-mm thick with irregular margins). They reserve the use of the term loosening for cases in which MRI demonstrates circumferential osseous resorption together with signs of implant displacement, subsidence, or rotation. In a study of 116 knees in 114 patients that evaluated the interface type (normal, fibrous membrane, fluid, or osteolysis), percent integration (<33%, 33%-66%, or >66%), and presence of bone marrow edema. | 69430 |
acrac_69430_18 | Imaging After Total Knee Arthroplasty | They determined MRI had higher sensitivity (84% versus 31%) but lower specificity (85% versus 96%) for patellar component loosening than did radiography [131]. MRI and CT have both been shown to be more sensitive for detection of osteolysis than radiographs [116]. MRI with metal artifact reduction techniques can detect osteolysis that is not visible on radiographs, even around the femoral component [96]. An MRI investigation of 11 TKA suspected of osteolysis on radiographs (and subsequently confirmed by surgery) found 10 cases with osteolysis at MRI and confirmed at surgery, 5 cases with additional osteolytic lesions detected on MRI, and 9 cases in which lesions were larger on MRI than on radiographs [97]. MRI can also show synovial changes due to particle disease before osteolytic lesions become apparent [22]. When effective, metal suppression can be used, and MRI can allow direct visualization of ligaments and tendons about the knee [93]. US Knee US has no significant role in assessing for aseptic prosthesis loosening and is not typically used for the assessment of osteolysis. US can be used to evaluate synovitis and soft tissues about the joint and to guide joint aspiration [132]. US is not typically used for assessment of instability but can be used to visualize and assess the medial and lateral collateral ligaments in the setting of TKA [133]. WBC Scan and Sulfur Colloid Scan Knee In-111 WBC, Tc-99m labeled WBC, and Tc-99m sulfur colloid knee scans are not useful for evaluation of aseptic knee prosthetic loosening. WBC/marrow studies are used to differentiate prosthetic loosening from acute infection and can be performed without or with a corresponding bone scan, the latter without altering the WBC/marrow results [127]. A negative WBC scan negates an acute neutrophilic infection but may be falsely negative in chronic infection [101]. | Imaging After Total Knee Arthroplasty. They determined MRI had higher sensitivity (84% versus 31%) but lower specificity (85% versus 96%) for patellar component loosening than did radiography [131]. MRI and CT have both been shown to be more sensitive for detection of osteolysis than radiographs [116]. MRI with metal artifact reduction techniques can detect osteolysis that is not visible on radiographs, even around the femoral component [96]. An MRI investigation of 11 TKA suspected of osteolysis on radiographs (and subsequently confirmed by surgery) found 10 cases with osteolysis at MRI and confirmed at surgery, 5 cases with additional osteolytic lesions detected on MRI, and 9 cases in which lesions were larger on MRI than on radiographs [97]. MRI can also show synovial changes due to particle disease before osteolytic lesions become apparent [22]. When effective, metal suppression can be used, and MRI can allow direct visualization of ligaments and tendons about the knee [93]. US Knee US has no significant role in assessing for aseptic prosthesis loosening and is not typically used for the assessment of osteolysis. US can be used to evaluate synovitis and soft tissues about the joint and to guide joint aspiration [132]. US is not typically used for assessment of instability but can be used to visualize and assess the medial and lateral collateral ligaments in the setting of TKA [133]. WBC Scan and Sulfur Colloid Scan Knee In-111 WBC, Tc-99m labeled WBC, and Tc-99m sulfur colloid knee scans are not useful for evaluation of aseptic knee prosthetic loosening. WBC/marrow studies are used to differentiate prosthetic loosening from acute infection and can be performed without or with a corresponding bone scan, the latter without altering the WBC/marrow results [127]. A negative WBC scan negates an acute neutrophilic infection but may be falsely negative in chronic infection [101]. | 69430 |
acrac_69430_19 | Imaging After Total Knee Arthroplasty | Love et al [109] reported WBC/marrow sensitivity, specificity, and accuracy as 96%, 87%, and 91%, respectively, for 150 total hip and knee replacements. Joseph et al [106] reported preoperative WBC/marrow imaging in 58 total hip and knee replacements with a sensitivity, specificity, and accuracy of 46%, 100%, and 88%, respectively. Palestro et al [107,134] described >90% accuracy and a specificity with a high sensitivity for WBC/marrow studies in the assessment of prosthetic joints. In the setting of chronic infection, differentiating chronic prosthetic infection from loosening can be more challenging, given that, in comparison with acute infections, chronic infections tend to have significantly fewer neutrophils, which are the predominant type of WBC labeled in an In-111 or Tc-99m-HMPAO WBC study, and radiolabeled WBCs are predominantly neutrophils. A decreased WBC sensitivity in osteomyelitis has also been attributed to a bacterial protective membrane or biofilm and to the effect of antibiotics [66]. Nonetheless, WBC/marrow scans to include SPECT/CT appear to be the imaging procedures of choice, with a high degree of accuracy for the failed joint prosthesis in the setting of a positive 3-phase bone scan because a negative WBC/marrow study does not include aseptic loosening [66]. In-111 WBC and Tc-99m sulfur colloid studies are not useful for assessment of instability. Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs. Periprosthetic fractures may occur either during or after surgery and can involve the femur, tibia, or patella. Among periprosthetic fractures, supracondylar distal femur fractures are most common, whereas patellar fractures are rare [135,136]. Supracondylar fractures occur in 0.3% to 2.5% of TKA, usually within 2 to 4 years after surgery, and often occur in the setting of low-energy trauma [136]. Tibial fractures are associated with loose components and malalignment. | Imaging After Total Knee Arthroplasty. Love et al [109] reported WBC/marrow sensitivity, specificity, and accuracy as 96%, 87%, and 91%, respectively, for 150 total hip and knee replacements. Joseph et al [106] reported preoperative WBC/marrow imaging in 58 total hip and knee replacements with a sensitivity, specificity, and accuracy of 46%, 100%, and 88%, respectively. Palestro et al [107,134] described >90% accuracy and a specificity with a high sensitivity for WBC/marrow studies in the assessment of prosthetic joints. In the setting of chronic infection, differentiating chronic prosthetic infection from loosening can be more challenging, given that, in comparison with acute infections, chronic infections tend to have significantly fewer neutrophils, which are the predominant type of WBC labeled in an In-111 or Tc-99m-HMPAO WBC study, and radiolabeled WBCs are predominantly neutrophils. A decreased WBC sensitivity in osteomyelitis has also been attributed to a bacterial protective membrane or biofilm and to the effect of antibiotics [66]. Nonetheless, WBC/marrow scans to include SPECT/CT appear to be the imaging procedures of choice, with a high degree of accuracy for the failed joint prosthesis in the setting of a positive 3-phase bone scan because a negative WBC/marrow study does not include aseptic loosening [66]. In-111 WBC and Tc-99m sulfur colloid studies are not useful for assessment of instability. Variant 4: Pain after total knee arthroplasty. Suspect periprosthetic or hardware fracture. Additional imaging following radiographs. Periprosthetic fractures may occur either during or after surgery and can involve the femur, tibia, or patella. Among periprosthetic fractures, supracondylar distal femur fractures are most common, whereas patellar fractures are rare [135,136]. Supracondylar fractures occur in 0.3% to 2.5% of TKA, usually within 2 to 4 years after surgery, and often occur in the setting of low-energy trauma [136]. Tibial fractures are associated with loose components and malalignment. | 69430 |
acrac_69430_20 | Imaging After Total Knee Arthroplasty | Patellar fractures are associated with rheumatoid arthritis, steroid use, osteonecrosis, and malalignment. Most patients with periprosthetic fractures are elderly, having poor bone stock. Treatment depends Imaging After Total Knee Arthroplasty on fracture classification, which often includes information regarding fracture location, degree of comminution, and position and stability of the prosthesis. 3-Phase Bone Scan Knee Radionuclide 3-phase bone scans can demonstrate increased activity at a site of periprosthetic fracture and can show fractures that are radiographically occult [137,138]. In older osteopenic individuals with low rates of bone remodeling, it may take 48 to 72 hours for the development of increased radionuclide activity at the site of fracture. Within 1 to 2 years after prosthesis surgery, the differential diagnosis for increased periprosthetic activity would include postoperative change; however, with serial imaging, this postoperative activity should decrease over time, whereas activity increasing over time would be suggestive of a prosthetic complication, such as a periprosthetic fracture, aseptic loosening, or infection. Therefore, no conclusion should be drawn on an isolated bone scan unless it yields a normal study. CT Arthrography Knee There is no benefit to intraarticular contrast. CT Knee With IV Contrast IV contrast is not helpful for CT assessment of periprosthetic fracture. CT Knee Without and With IV Contrast IV contrast is not helpful for CT assessment of periprosthetic fracture. CT Knee Without IV Contrast Radiographically occult fractures may be detected on CT when metal artifact reduction techniques are used [20]. FDG-PET/CT Whole Body There is insufficient evidence to support the use of FDG-PET/CT for the assessment of periprosthetic fractures. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the assessment of periprosthetic fractures. | Imaging After Total Knee Arthroplasty. Patellar fractures are associated with rheumatoid arthritis, steroid use, osteonecrosis, and malalignment. Most patients with periprosthetic fractures are elderly, having poor bone stock. Treatment depends Imaging After Total Knee Arthroplasty on fracture classification, which often includes information regarding fracture location, degree of comminution, and position and stability of the prosthesis. 3-Phase Bone Scan Knee Radionuclide 3-phase bone scans can demonstrate increased activity at a site of periprosthetic fracture and can show fractures that are radiographically occult [137,138]. In older osteopenic individuals with low rates of bone remodeling, it may take 48 to 72 hours for the development of increased radionuclide activity at the site of fracture. Within 1 to 2 years after prosthesis surgery, the differential diagnosis for increased periprosthetic activity would include postoperative change; however, with serial imaging, this postoperative activity should decrease over time, whereas activity increasing over time would be suggestive of a prosthetic complication, such as a periprosthetic fracture, aseptic loosening, or infection. Therefore, no conclusion should be drawn on an isolated bone scan unless it yields a normal study. CT Arthrography Knee There is no benefit to intraarticular contrast. CT Knee With IV Contrast IV contrast is not helpful for CT assessment of periprosthetic fracture. CT Knee Without and With IV Contrast IV contrast is not helpful for CT assessment of periprosthetic fracture. CT Knee Without IV Contrast Radiographically occult fractures may be detected on CT when metal artifact reduction techniques are used [20]. FDG-PET/CT Whole Body There is insufficient evidence to support the use of FDG-PET/CT for the assessment of periprosthetic fractures. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the assessment of periprosthetic fractures. | 69430 |
acrac_69430_21 | Imaging After Total Knee Arthroplasty | Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the assessment of periprosthetic fractures. MRI Knee Without and With IV Contrast IV contrast is not helpful for CT or MRI assessment of periprosthetic fracture. MRI Knee Without IV Contrast Radiographically occult fractures may be detected on MRI [22] when metal artifact reduction techniques are used. US Knee There is insufficient evidence to support the use of US for the assessment of periprosthetic fractures. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of In-111 WBC and Tc-99m sulfur colloid studies for the assessment of periprosthetic fractures. Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs. Malposition of femoral and tibial components may affect patellar alignment [139]. Excessive combined internal rotation of tibial and femoral components has been shown to be associated with patellar complications [139]. Moreover, Berger and Rubash [140] found that the amount of excessive combined internal rotation is directly proportional to the severity of patellofemoral complications. Abdelnasser et al [141] noted an internal rotation of the tibial component in TKA can lead to postoperative extension deficit. 3-Phase Bone Scan Knee There is insufficient evidence to support the use of bone scans for the assessment of rotational alignment of a TKA. CT Arthrography Knee Intraarticular contrast is not helpful in the CT assessment of rotational alignment. CT Knee With IV Contrast IV contrast is not helpful in the CT assessment of rotational alignment. Imaging After Total Knee Arthroplasty CT Knee Without and With IV Contrast IV contrast is not helpful in the CT assessment of rotational alignment. | Imaging After Total Knee Arthroplasty. Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the assessment of periprosthetic fractures. MRI Knee Without and With IV Contrast IV contrast is not helpful for CT or MRI assessment of periprosthetic fracture. MRI Knee Without IV Contrast Radiographically occult fractures may be detected on MRI [22] when metal artifact reduction techniques are used. US Knee There is insufficient evidence to support the use of US for the assessment of periprosthetic fractures. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of In-111 WBC and Tc-99m sulfur colloid studies for the assessment of periprosthetic fractures. Variant 5: Pain after total knee arthroplasty. Measuring component rotation. Additional imaging following radiographs. Malposition of femoral and tibial components may affect patellar alignment [139]. Excessive combined internal rotation of tibial and femoral components has been shown to be associated with patellar complications [139]. Moreover, Berger and Rubash [140] found that the amount of excessive combined internal rotation is directly proportional to the severity of patellofemoral complications. Abdelnasser et al [141] noted an internal rotation of the tibial component in TKA can lead to postoperative extension deficit. 3-Phase Bone Scan Knee There is insufficient evidence to support the use of bone scans for the assessment of rotational alignment of a TKA. CT Arthrography Knee Intraarticular contrast is not helpful in the CT assessment of rotational alignment. CT Knee With IV Contrast IV contrast is not helpful in the CT assessment of rotational alignment. Imaging After Total Knee Arthroplasty CT Knee Without and With IV Contrast IV contrast is not helpful in the CT assessment of rotational alignment. | 69430 |
acrac_69430_22 | Imaging After Total Knee Arthroplasty | FDG-PET/CT Whole Body Stumpe et al [79] found diffuse synovial and focal extrasynovial FDG uptake in patients with component malrotation; however, FDG-PET/CT studies are not routinely used for the assessment of rotational alignment of a TKA. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the assessment of rotational alignment of a TKA. Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the assessment of rotational alignment of a TKA. MRI Knee Without and With IV Contrast IV contrast is not useful for MRI assessment of rotational alignment. MRI Knee Without IV Contrast When adequate metal reduction techniques are used, MRI can be used to assess TKA component rotation [146]. Anatomic landmarks and axes required for measurement of rotational alignment parameters can be identified [147,148]. In a study of 50 patients with painful TKA and 16 controls, Murakami et al [148] found high interobserver agreement in all the relevant rotational alignment measurements and found statistically significant relative internal rotation of the femoral component in patients with a painful TKA. MRI literature is evolving, and the available evidence suggests MRI may be useful in the assessment of component rotation with adequate metal reduction techniques. US Knee There is insufficient evidence to support the use of US for the assessment of rotational alignment of a TKA. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of In-111 WBC and Tc-99m sulfur colloid studies for the assessment of rotational alignment of a TKA. Variant 6: Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy (quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues). Additional imaging following radiographs. | Imaging After Total Knee Arthroplasty. FDG-PET/CT Whole Body Stumpe et al [79] found diffuse synovial and focal extrasynovial FDG uptake in patients with component malrotation; however, FDG-PET/CT studies are not routinely used for the assessment of rotational alignment of a TKA. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the assessment of rotational alignment of a TKA. Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the assessment of rotational alignment of a TKA. MRI Knee Without and With IV Contrast IV contrast is not useful for MRI assessment of rotational alignment. MRI Knee Without IV Contrast When adequate metal reduction techniques are used, MRI can be used to assess TKA component rotation [146]. Anatomic landmarks and axes required for measurement of rotational alignment parameters can be identified [147,148]. In a study of 50 patients with painful TKA and 16 controls, Murakami et al [148] found high interobserver agreement in all the relevant rotational alignment measurements and found statistically significant relative internal rotation of the femoral component in patients with a painful TKA. MRI literature is evolving, and the available evidence suggests MRI may be useful in the assessment of component rotation with adequate metal reduction techniques. US Knee There is insufficient evidence to support the use of US for the assessment of rotational alignment of a TKA. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of In-111 WBC and Tc-99m sulfur colloid studies for the assessment of rotational alignment of a TKA. Variant 6: Pain after total knee arthroplasty. Suspect periprosthetic soft-tissue abnormality unrelated to infection, including quadriceps or patellar tendinopathy (quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues). Additional imaging following radiographs. | 69430 |
acrac_69430_23 | Imaging After Total Knee Arthroplasty | The incidence of quadriceps or patellar tendon tears after TKA is low, at 0.17% to 2.5% [149]. Sharkey et al [12] reported that the incidence of postoperative arthrofibrosis is also relatively low, accounting for 4.5% of failures in this series and 6.9% of failures where noted in the Lombardi et al [111] series. Of note, patients with keloids have increased odds risk of arthrofibrosis following primary TKA [150]. Additional periprosthetic soft-tissue causes of postoperative knee pain are also uncommon and include impingement of nerves or other soft tissues. Imaging After Total Knee Arthroplasty 3-Phase Bone Scan Knee There is insufficient evidence to support the use of 3-phase bone scan for the assessment of periprosthetic soft- tissue abnormalities. CT Arthrography Knee CT is not useful for assessment of periprosthetic soft-tissue abnormalities. Intraarticular contrast is not significantly helpful in the CT assessment of quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues. CT Knee With IV Contrast CT is not useful for assessment of periprosthetic soft-tissue abnormalities. IV contrast is not significantly helpful in the CT assessment of quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues. CT Knee Without and With IV Contrast CT is not useful for assessment of periprosthetic soft-tissue abnormalities. IV contrast is not significantly helpful in the CT assessment of quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues. CT Knee Without IV Contrast There is insufficient evidence to support the use of CT without IV contrast for the assessment of periprosthetic soft- tissue abnormalities. | Imaging After Total Knee Arthroplasty. The incidence of quadriceps or patellar tendon tears after TKA is low, at 0.17% to 2.5% [149]. Sharkey et al [12] reported that the incidence of postoperative arthrofibrosis is also relatively low, accounting for 4.5% of failures in this series and 6.9% of failures where noted in the Lombardi et al [111] series. Of note, patients with keloids have increased odds risk of arthrofibrosis following primary TKA [150]. Additional periprosthetic soft-tissue causes of postoperative knee pain are also uncommon and include impingement of nerves or other soft tissues. Imaging After Total Knee Arthroplasty 3-Phase Bone Scan Knee There is insufficient evidence to support the use of 3-phase bone scan for the assessment of periprosthetic soft- tissue abnormalities. CT Arthrography Knee CT is not useful for assessment of periprosthetic soft-tissue abnormalities. Intraarticular contrast is not significantly helpful in the CT assessment of quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues. CT Knee With IV Contrast CT is not useful for assessment of periprosthetic soft-tissue abnormalities. IV contrast is not significantly helpful in the CT assessment of quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues. CT Knee Without and With IV Contrast CT is not useful for assessment of periprosthetic soft-tissue abnormalities. IV contrast is not significantly helpful in the CT assessment of quadriceps or patellar tendon tears, postoperative arthrofibrosis, patellar clunk syndrome, or impingement of nerves or other soft tissues. CT Knee Without IV Contrast There is insufficient evidence to support the use of CT without IV contrast for the assessment of periprosthetic soft- tissue abnormalities. | 69430 |
acrac_69430_24 | Imaging After Total Knee Arthroplasty | FDG-PET/CT Whole Body There is insufficient evidence to support the use of FDG-PET/CT for the assessment of periprosthetic soft-tissue abnormalities. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the assessment of periprosthetic soft-tissue abnormalities. Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the assessment of periprosthetic soft-tissue abnormalities. MRI Knee Without IV Contrast MRI that uses robust metal reduction techniques can be used for evaluation of quadriceps or patellar tendinopathy in patients with TKA [152] and for evaluation of arthrofibrosis [93]. MRI can also demonstrate suprapatellar arthrofibrosis that can be associated with post TKA patellar clunk syndrome [147]. The presence of MRI measurable abundant thick fibrotic tissue in patients with a clinical diagnosis of knee fibrosis is of benefit to knee surgeons faced with patients with stiff TKA and can facilitate the decision to debride the knee, restore range of motion, and revise the implant [153]. MRI is beneficial for the workup of periarticular soft-tissue masses, including neoplastic masses and inflammatory pseudotumors [154]. US Knee US can be used for evaluation of quadriceps or patellar tendinopathy [155-157], postsurgical arthrofibrosis [158], and periarticular soft-tissue masses in patients with TKA. One review discusses the use of dynamic US to look for causes of snapping knee, including patellar clunk, snapping popliteus, and snapping related to component/liner malposition [159]. A case report discussed the utility of using dynamic US for the workup of patellar clunk syndrome [160]. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of In-111 WBC and Tc-99m sulfur colloid studies for the assessment of periprosthetic soft-tissue abnormalities. | Imaging After Total Knee Arthroplasty. FDG-PET/CT Whole Body There is insufficient evidence to support the use of FDG-PET/CT for the assessment of periprosthetic soft-tissue abnormalities. Fluoride PET/CT Whole Body There is insufficient evidence to support the use of fluoride PET/CT for the assessment of periprosthetic soft-tissue abnormalities. Fluoroscopy Knee There is insufficient evidence to support the use of fluoroscopy for the assessment of periprosthetic soft-tissue abnormalities. MRI Knee Without IV Contrast MRI that uses robust metal reduction techniques can be used for evaluation of quadriceps or patellar tendinopathy in patients with TKA [152] and for evaluation of arthrofibrosis [93]. MRI can also demonstrate suprapatellar arthrofibrosis that can be associated with post TKA patellar clunk syndrome [147]. The presence of MRI measurable abundant thick fibrotic tissue in patients with a clinical diagnosis of knee fibrosis is of benefit to knee surgeons faced with patients with stiff TKA and can facilitate the decision to debride the knee, restore range of motion, and revise the implant [153]. MRI is beneficial for the workup of periarticular soft-tissue masses, including neoplastic masses and inflammatory pseudotumors [154]. US Knee US can be used for evaluation of quadriceps or patellar tendinopathy [155-157], postsurgical arthrofibrosis [158], and periarticular soft-tissue masses in patients with TKA. One review discusses the use of dynamic US to look for causes of snapping knee, including patellar clunk, snapping popliteus, and snapping related to component/liner malposition [159]. A case report discussed the utility of using dynamic US for the workup of patellar clunk syndrome [160]. WBC Scan and Sulfur Colloid Scan Knee There is insufficient evidence to support the use of In-111 WBC and Tc-99m sulfur colloid studies for the assessment of periprosthetic soft-tissue abnormalities. | 69430 |
acrac_3083021_0 | Head Trauma Child PCAs | Introduction/Background Head trauma is a common indication for cranial imaging in children. Although traumatic brain injury is a leading cause of death and disability in children [1], the vast majority of head injuries are uncomplicated, transient, and do not require intervention [2]. The necessity of identifying clinically relevant, potentially treatable injury must be weighed against the risks of performing unwarranted imaging studies, possible unnecessary sedation, and inappropriate resource utilization. The precise criteria for minor head injury are not consistent in the literature, but this usually refers to a patient with normal or near-normal postevent mental status and is often defined by a Glasgow Coma Scale (GCS) of 14 or 15 [3]. The probability of significant anatomic injury in minor head trauma is low. Approximately 3% to 5% of children with minor head trauma have identifiable abnormalities by imaging but typically less than 1% requires neurosurgical intervention [4-7]. 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] Head Trauma-Child injury but resulted in a relatively high rate of CTs [13]. Additional smaller validation trials in the United States and abroad have also determined the PECARN criteria for very low risk criteria to be 100% sensitive [14-17]. | Head Trauma Child PCAs. Introduction/Background Head trauma is a common indication for cranial imaging in children. Although traumatic brain injury is a leading cause of death and disability in children [1], the vast majority of head injuries are uncomplicated, transient, and do not require intervention [2]. The necessity of identifying clinically relevant, potentially treatable injury must be weighed against the risks of performing unwarranted imaging studies, possible unnecessary sedation, and inappropriate resource utilization. The precise criteria for minor head injury are not consistent in the literature, but this usually refers to a patient with normal or near-normal postevent mental status and is often defined by a Glasgow Coma Scale (GCS) of 14 or 15 [3]. The probability of significant anatomic injury in minor head trauma is low. Approximately 3% to 5% of children with minor head trauma have identifiable abnormalities by imaging but typically less than 1% requires neurosurgical intervention [4-7]. 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] Head Trauma-Child injury but resulted in a relatively high rate of CTs [13]. Additional smaller validation trials in the United States and abroad have also determined the PECARN criteria for very low risk criteria to be 100% sensitive [14-17]. | 3083021 |
acrac_3083021_1 | Head Trauma Child PCAs | Although precise comparison among the clinical decision rules is limited by differences in methodology and outcomes, the PECARN criteria remain the most widely validated, particularly for very young children, because of the high sensitivity and strong validation; the PECARN guidelines have been incorporated into the clinical variants for acute minor pediatric head trauma imaging. The PECARN criteria are summarized in Appendix 1. MRI The identification of small bleeds, particularly in the posterior fossa or brainstem, is further increased with hemesensitive techniques such as susceptibility-weighted imaging [2,24-26]. Diffusion-weighted imaging can be helpful in identifying nonhemorrhagic injuries and associated ischemia as well [27]. Standard MRI sequences have a low sensitivity for skull fractures. In recent years, limited rapid brain MRI techniques have been investigated as a means to evaluate pediatric head trauma without the need for sedation. Preliminary data suggest variations of this method may be helpful in following known intracranial hemorrhage documented by CT, but the sensitivity of rapid MRI in lieu of CT remains uncertain [28-31]. Additionally, there is no single uniform definition for rapid brain MRI techniques, and protocols vary among institutions. This is a rapidly evolving area of investigation but, at this time, there is no distinct procedural assignment for fast brain MRI in the ACR lexicon. Ultrasound A few recent studies in children have suggested ultrasound (US) can detect calvarial fractures with a sensitivity close to that of CT [32]. However, even in infants with open fontanelles, in which US imaging of the brain is possible, US lacks sensitivity for small subdural hematomas, particularly in the posterior fossa, as well as other small extra-axial hemorrhages. | Head Trauma Child PCAs. Although precise comparison among the clinical decision rules is limited by differences in methodology and outcomes, the PECARN criteria remain the most widely validated, particularly for very young children, because of the high sensitivity and strong validation; the PECARN guidelines have been incorporated into the clinical variants for acute minor pediatric head trauma imaging. The PECARN criteria are summarized in Appendix 1. MRI The identification of small bleeds, particularly in the posterior fossa or brainstem, is further increased with hemesensitive techniques such as susceptibility-weighted imaging [2,24-26]. Diffusion-weighted imaging can be helpful in identifying nonhemorrhagic injuries and associated ischemia as well [27]. Standard MRI sequences have a low sensitivity for skull fractures. In recent years, limited rapid brain MRI techniques have been investigated as a means to evaluate pediatric head trauma without the need for sedation. Preliminary data suggest variations of this method may be helpful in following known intracranial hemorrhage documented by CT, but the sensitivity of rapid MRI in lieu of CT remains uncertain [28-31]. Additionally, there is no single uniform definition for rapid brain MRI techniques, and protocols vary among institutions. This is a rapidly evolving area of investigation but, at this time, there is no distinct procedural assignment for fast brain MRI in the ACR lexicon. Ultrasound A few recent studies in children have suggested ultrasound (US) can detect calvarial fractures with a sensitivity close to that of CT [32]. However, even in infants with open fontanelles, in which US imaging of the brain is possible, US lacks sensitivity for small subdural hematomas, particularly in the posterior fossa, as well as other small extra-axial hemorrhages. | 3083021 |
acrac_3083021_2 | Head Trauma Child PCAs | Because intracranial injury can occur with or without fractures and US does not have a high sensitivity for hemorrhages, it does not currently have a significant role in head trauma imaging and as such is not considered in these variant procedures. Discussion of Procedures by Variant Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. Head Trauma-Child CTA Head There is no relevant literature or expert consensus supporting the use of CT angiography (CTA) in the initial evaluation of children with minor trauma and very low risk for intracranial injury. MRI Head There is no relevant literature or expert consensus supporting the use of MRI in the initial evaluation of children with minor trauma and very low risk for intracranial injury. MRA Head There is no relevant literature or expert consensus supporting the use of MR angiography (MRA) in the initial evaluation of children with minor trauma and very low risk for intracranial injury. Arteriography Cerebral There is no relevant literature or expert consensus supporting the use of conventional cerebral angiography in the initial evaluation of children with minor trauma and very low risk for intracranial injury. Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. | Head Trauma Child PCAs. Because intracranial injury can occur with or without fractures and US does not have a high sensitivity for hemorrhages, it does not currently have a significant role in head trauma imaging and as such is not considered in these variant procedures. Discussion of Procedures by Variant Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. Head Trauma-Child CTA Head There is no relevant literature or expert consensus supporting the use of CT angiography (CTA) in the initial evaluation of children with minor trauma and very low risk for intracranial injury. MRI Head There is no relevant literature or expert consensus supporting the use of MRI in the initial evaluation of children with minor trauma and very low risk for intracranial injury. MRA Head There is no relevant literature or expert consensus supporting the use of MR angiography (MRA) in the initial evaluation of children with minor trauma and very low risk for intracranial injury. Arteriography Cerebral There is no relevant literature or expert consensus supporting the use of conventional cerebral angiography in the initial evaluation of children with minor trauma and very low risk for intracranial injury. Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. | 3083021 |
acrac_3083021_3 | Head Trauma Child PCAs | CT may be considered in lieu of careful clinical observation in instances of parental preference, multiple risk factors, worsening clinical symptoms or signs during observation, and in young infants in which observational assessment is more challenging. Head Trauma-Child CTA Head There is no relevant literature or expert consensus supporting the use of CTA in the initial evaluation of children with minor head injury and intermediate risk for intracranial injury. MRI Head MRI is sensitive for acute intracranial hemorrhage and other intracranial traumatic injury. However, MRI in the acute setting is frequently impractical. The examination requires preimaging safety screening, is significantly longer than CT, and younger children often need sedation to compete the examination, further delaying time to imaging. IV contrast is typically of little use in evaluation of acute trauma. MRA Head There is no relevant literature or expert consensus supporting the use of MRA in the initial evaluation of children with minor head injury and intermediate risk for intracranial injury. Arteriography Cerebral There is no relevant literature or expert consensus supporting the use of conventional cerebral angiography in the initial evaluation of children with minor head injury and intermediate risk for intracranial injury. Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. High-risk factors for intracranial injury from minor head trauma in children <2 years of age by PECARN criteria include those with a GCS of 14, other signs of altered mental status, or signs of any palpable skull fracture. | Head Trauma Child PCAs. CT may be considered in lieu of careful clinical observation in instances of parental preference, multiple risk factors, worsening clinical symptoms or signs during observation, and in young infants in which observational assessment is more challenging. Head Trauma-Child CTA Head There is no relevant literature or expert consensus supporting the use of CTA in the initial evaluation of children with minor head injury and intermediate risk for intracranial injury. MRI Head MRI is sensitive for acute intracranial hemorrhage and other intracranial traumatic injury. However, MRI in the acute setting is frequently impractical. The examination requires preimaging safety screening, is significantly longer than CT, and younger children often need sedation to compete the examination, further delaying time to imaging. IV contrast is typically of little use in evaluation of acute trauma. MRA Head There is no relevant literature or expert consensus supporting the use of MRA in the initial evaluation of children with minor head injury and intermediate risk for intracranial injury. Arteriography Cerebral There is no relevant literature or expert consensus supporting the use of conventional cerebral angiography in the initial evaluation of children with minor head injury and intermediate risk for intracranial injury. Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. High-risk factors for intracranial injury from minor head trauma in children <2 years of age by PECARN criteria include those with a GCS of 14, other signs of altered mental status, or signs of any palpable skull fracture. | 3083021 |
acrac_3083021_4 | Head Trauma Child PCAs | The risk of clinically significant intracranial injury in these patients is estimated at approximately 4.4% [5]. Although still relatively uncommon, the risk of interveneable injury is substantial enough that imaging is strongly recommended. CT has the advantage of rapid acquisition and excellent sensitivity for acute intracranial hemorrhage and fractures. CTA Head Most vascular injuries in children are cervical, and there remains a relative paucity of evidence-based literature regarding the prevalence and nature of isolated intracranial vascular injury in pediatric head trauma. Intracranial vascular injuries have been reported in children with minor head trauma but are likely uncommon [19,34,35]. Vascular imaging is usually not a standard component of initial first-line imaging evaluation in patients with minor head trauma. However, if there are clinical symptoms or signs on other imaging raising suspicion for vascular injury, such as basilar fracture through a vascular canal, CTA may be considered for rapid assessment in the acute setting. MRI Head MRI is sensitive for acute intracranial hemorrhage and other intracranial traumatic injuries. However, MRI in the emergent setting is frequently impractical. The examination is typically significantly longer than CT, requires safety screening, results take longer to obtain, and younger children often need sedation to complete the examination, further delaying assessment. IV contrast is typically of little use in evaluation of acute trauma. MRA Head There remains a relative paucity of evidence-based literature regarding the prevalence and nature of vascular injury in minor pediatric head trauma. Vascular injuries have been reported in children with minor head trauma but are likely uncommon [19,34,35]. Vascular imaging is generally not a standard component of initial first-line imaging evaluation in patients with minor head trauma. If there are clinical or other imaging signs suggestive of vascular injury, MRA could be considered. | Head Trauma Child PCAs. The risk of clinically significant intracranial injury in these patients is estimated at approximately 4.4% [5]. Although still relatively uncommon, the risk of interveneable injury is substantial enough that imaging is strongly recommended. CT has the advantage of rapid acquisition and excellent sensitivity for acute intracranial hemorrhage and fractures. CTA Head Most vascular injuries in children are cervical, and there remains a relative paucity of evidence-based literature regarding the prevalence and nature of isolated intracranial vascular injury in pediatric head trauma. Intracranial vascular injuries have been reported in children with minor head trauma but are likely uncommon [19,34,35]. Vascular imaging is usually not a standard component of initial first-line imaging evaluation in patients with minor head trauma. However, if there are clinical symptoms or signs on other imaging raising suspicion for vascular injury, such as basilar fracture through a vascular canal, CTA may be considered for rapid assessment in the acute setting. MRI Head MRI is sensitive for acute intracranial hemorrhage and other intracranial traumatic injuries. However, MRI in the emergent setting is frequently impractical. The examination is typically significantly longer than CT, requires safety screening, results take longer to obtain, and younger children often need sedation to complete the examination, further delaying assessment. IV contrast is typically of little use in evaluation of acute trauma. MRA Head There remains a relative paucity of evidence-based literature regarding the prevalence and nature of vascular injury in minor pediatric head trauma. Vascular injuries have been reported in children with minor head trauma but are likely uncommon [19,34,35]. Vascular imaging is generally not a standard component of initial first-line imaging evaluation in patients with minor head trauma. If there are clinical or other imaging signs suggestive of vascular injury, MRA could be considered. | 3083021 |
acrac_3083021_5 | Head Trauma Child PCAs | MRA can be performed without IV contrast using time-of-flight sequences, although IV contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Head Trauma-Child Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. CT Head Moderate and severe head injury is typically associated with post-traumatic mental status changes. Despite the lower incidence and fewer numbers of studies addressing more significant injury in children, there is little debate regarding the need for imaging because of the greater incidence of intracranial injury in patients with decreased GCS [36]. CT has the advantage of rapid acquisition and excellent sensitivity for traumatic injuries, such as herniation or hemorrhage, which benefit from prompt intervention. CTA Head Imaging for vascular injury is primarily guided by clinical suspicion or imaging findings, such as fracture through the skull base or vascular channels. Most literature regarding vascular injury in the pediatric population is confined to small series, and the true incidence and natural history of these injuries in children remains uncertain [19]. However, vascular imaging should be considered in patients with evidence of arterial stroke by examination or by imaging as well as those with fractures extending through the skull base or vascular channels, which are typically encountered in higher impact traumas [37,38]. CTA provides high spatial resolution and rapid assessment for vascular injuries. | Head Trauma Child PCAs. MRA can be performed without IV contrast using time-of-flight sequences, although IV contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Head Trauma-Child Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging. Radiography Skull Not all skull fractures are evident by radiographs, and up to 50% of intracranial injuries in children occur in the absence of fracture [2,33]. Therefore, radiographs are not sufficient to evaluate for traumatic injury [9]. CT Head Moderate and severe head injury is typically associated with post-traumatic mental status changes. Despite the lower incidence and fewer numbers of studies addressing more significant injury in children, there is little debate regarding the need for imaging because of the greater incidence of intracranial injury in patients with decreased GCS [36]. CT has the advantage of rapid acquisition and excellent sensitivity for traumatic injuries, such as herniation or hemorrhage, which benefit from prompt intervention. CTA Head Imaging for vascular injury is primarily guided by clinical suspicion or imaging findings, such as fracture through the skull base or vascular channels. Most literature regarding vascular injury in the pediatric population is confined to small series, and the true incidence and natural history of these injuries in children remains uncertain [19]. However, vascular imaging should be considered in patients with evidence of arterial stroke by examination or by imaging as well as those with fractures extending through the skull base or vascular channels, which are typically encountered in higher impact traumas [37,38]. CTA provides high spatial resolution and rapid assessment for vascular injuries. | 3083021 |
acrac_3083021_6 | Head Trauma Child PCAs | MRI Head Patients with more significant trauma and lower GCS are more likely to have sustained shear injury or ischemia, and MRI may have a higher yield for prognosis in this instance [25,39]. However, because of the time required to arrange and perform the examination and possible need for sedation, MRI can be difficult to accomplish emergently and should not delay evaluation. IV contrast is typically of little use in evaluation of acute trauma. MRA Head MRA can evaluate the intracranial vasculature and can be performed in conjunction with MRI when vascular injury is clinically suspected. However, as with standard MRI, this examination may be difficult to perform emergently. MRA can be performed without contrast using time-of-flight sequences, although IV contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Arteriography Cerebral Conventional cerebral angiography remains the definitive diagnostic test for vascular injury and can demonstrate subtle abnormalities that may be occult on either CTA or MRA. However, because of the invasive procedure and need for sedation, conventional angiography should be reserved for problem solving in cases with uncertain noninvasive imaging and high clinical suspicion of vascular injury. Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs. The exact definition of subacute injury varies, but subacute head injury is typically defined as occurring between 8 days and 1 month after the initial traumatic event [40,41]. Injury may be caused by secondary processes, such as herniation from worsening parenchymal edema, ischemia, hydrocephalus, and progressive or delayed hemorrhage. During the subacute phase, up to 30% of contusions may cause worsening mass effect with edema from toxic metabolites released into the surrounding tissue and cerebral autoregulation dysfunction [42]. | Head Trauma Child PCAs. MRI Head Patients with more significant trauma and lower GCS are more likely to have sustained shear injury or ischemia, and MRI may have a higher yield for prognosis in this instance [25,39]. However, because of the time required to arrange and perform the examination and possible need for sedation, MRI can be difficult to accomplish emergently and should not delay evaluation. IV contrast is typically of little use in evaluation of acute trauma. MRA Head MRA can evaluate the intracranial vasculature and can be performed in conjunction with MRI when vascular injury is clinically suspected. However, as with standard MRI, this examination may be difficult to perform emergently. MRA can be performed without contrast using time-of-flight sequences, although IV contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Arteriography Cerebral Conventional cerebral angiography remains the definitive diagnostic test for vascular injury and can demonstrate subtle abnormalities that may be occult on either CTA or MRA. However, because of the invasive procedure and need for sedation, conventional angiography should be reserved for problem solving in cases with uncertain noninvasive imaging and high clinical suspicion of vascular injury. Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs. The exact definition of subacute injury varies, but subacute head injury is typically defined as occurring between 8 days and 1 month after the initial traumatic event [40,41]. Injury may be caused by secondary processes, such as herniation from worsening parenchymal edema, ischemia, hydrocephalus, and progressive or delayed hemorrhage. During the subacute phase, up to 30% of contusions may cause worsening mass effect with edema from toxic metabolites released into the surrounding tissue and cerebral autoregulation dysfunction [42]. | 3083021 |
acrac_3083021_7 | Head Trauma Child PCAs | Radiography Skull There is no relevant literature or expert consensus regarding the use of skull radiographs in children with subacute head trauma and cognitive or neurologic signs. CT Head Patients with a significant change in neurologic status are at a high risk for progressive intracranial injury, may require neurosurgical intervention, and may benefit from imaging [43]. CT can provide rapid, accurate assessment for progressive hemorrhage, herniation, and hydrocephalus. In one study of 116 children with CT positive for Head Trauma-Child traumatic head injury, 9 patients experienced neurologic deterioration, 6 of whom required neurosurgery [44]. However, all patients undergoing intervention were identified clinically, without imaging, reflecting the importance of clinical examination in this population. CTA Head Imaging for vascular injury is primarily guided by clinical suspicion. Most literature regarding vascular injury in the pediatric population is confined to small series, and the true incidence and natural history of these injuries in children remains uncertain [19]. However, vascular imaging should be considered in patients with evidence of arterial stroke by examination or by imaging as well as those with fractures extending through the skull base vascular channels [37]. CTA provides high spatial resolution and rapid assessment for vascular injury. MRI Head MRI may be helpful in evaluating persistent, unexplained, or new neurological deficits in the subacute setting. MRI has a high sensitivity for blood products, including small brainstem and infratentorial hemorrhages as well as subacute hemorrhage, which becomes less dense on CT over time. The superior detection of nonhemorrhagic contusions and ischemia may be particularly helpful in the absence of findings on prior CT [38]. However, a standard MRI requires the patient be stable enough to tolerate a lengthier examination. | Head Trauma Child PCAs. Radiography Skull There is no relevant literature or expert consensus regarding the use of skull radiographs in children with subacute head trauma and cognitive or neurologic signs. CT Head Patients with a significant change in neurologic status are at a high risk for progressive intracranial injury, may require neurosurgical intervention, and may benefit from imaging [43]. CT can provide rapid, accurate assessment for progressive hemorrhage, herniation, and hydrocephalus. In one study of 116 children with CT positive for Head Trauma-Child traumatic head injury, 9 patients experienced neurologic deterioration, 6 of whom required neurosurgery [44]. However, all patients undergoing intervention were identified clinically, without imaging, reflecting the importance of clinical examination in this population. CTA Head Imaging for vascular injury is primarily guided by clinical suspicion. Most literature regarding vascular injury in the pediatric population is confined to small series, and the true incidence and natural history of these injuries in children remains uncertain [19]. However, vascular imaging should be considered in patients with evidence of arterial stroke by examination or by imaging as well as those with fractures extending through the skull base vascular channels [37]. CTA provides high spatial resolution and rapid assessment for vascular injury. MRI Head MRI may be helpful in evaluating persistent, unexplained, or new neurological deficits in the subacute setting. MRI has a high sensitivity for blood products, including small brainstem and infratentorial hemorrhages as well as subacute hemorrhage, which becomes less dense on CT over time. The superior detection of nonhemorrhagic contusions and ischemia may be particularly helpful in the absence of findings on prior CT [38]. However, a standard MRI requires the patient be stable enough to tolerate a lengthier examination. | 3083021 |
acrac_3083021_8 | Head Trauma Child PCAs | In recent years, limited rapid MRI techniques have been investigated as a means to evaluate pediatric head trauma without the need for sedation. Preliminary data suggest variations of this method may be helpful in following known intracranial hemorrhage documented by CT, but the sensitivity of rapid MRI in lieu of CT remains uncertain [28-31]. Contrast-enhanced sequences are generally not indicated unless there is a concern for infection, such as from penetrating injury or fractures involving the sinuses. MRA Head MRA can evaluate the intracranial vasculature and can be performed in conjunction with MRI when vascular injury is clinically suspected. However, as with standard MRI, it may be difficult to perform emergently. MRA can be performed without IV contrast using time-of-flight sequences, although IV contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Arteriography Cerebral Conventional cerebral angiography remains the definitive diagnostic test for vascular injury and can demonstrate subtle abnormalities that may be occult on either CTA or MRA. However, because of the invasive procedure and need for sedation, conventional angiography should be reserved for problem solving in cases with uncertain noninvasive imaging and high clinical suspicion of injury. Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure. Postconcussion symptoms are common after head injury. In mild traumatic cases, imaging in the chronic setting is usually negative, and in cases in which more severe trauma or prior intracranial injury has occurred, imaging in the chronic period rarely reveals additional actionable changes [45-47]. CT Head There are little data regarding the use of CT in children in the chronic post-traumatic setting. | Head Trauma Child PCAs. In recent years, limited rapid MRI techniques have been investigated as a means to evaluate pediatric head trauma without the need for sedation. Preliminary data suggest variations of this method may be helpful in following known intracranial hemorrhage documented by CT, but the sensitivity of rapid MRI in lieu of CT remains uncertain [28-31]. Contrast-enhanced sequences are generally not indicated unless there is a concern for infection, such as from penetrating injury or fractures involving the sinuses. MRA Head MRA can evaluate the intracranial vasculature and can be performed in conjunction with MRI when vascular injury is clinically suspected. However, as with standard MRI, it may be difficult to perform emergently. MRA can be performed without IV contrast using time-of-flight sequences, although IV contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Arteriography Cerebral Conventional cerebral angiography remains the definitive diagnostic test for vascular injury and can demonstrate subtle abnormalities that may be occult on either CTA or MRA. However, because of the invasive procedure and need for sedation, conventional angiography should be reserved for problem solving in cases with uncertain noninvasive imaging and high clinical suspicion of injury. Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure. Postconcussion symptoms are common after head injury. In mild traumatic cases, imaging in the chronic setting is usually negative, and in cases in which more severe trauma or prior intracranial injury has occurred, imaging in the chronic period rarely reveals additional actionable changes [45-47]. CT Head There are little data regarding the use of CT in children in the chronic post-traumatic setting. | 3083021 |
acrac_3083021_9 | Head Trauma Child PCAs | A few studies addressing CT is this setting support a low diagnostic yield for imaging in the post-traumatic setting [46,47]. One study of 52 children with chronic head injury demonstrated CTs performed on only 8 patients [46]. One patient was found to have a fracture. No intracranial injury was detected. CT has limited sensitivity for nonacute intracranial hemorrhage and small contusions. CT likely has little role in evaluating most children with chronic head injury but may be a consideration when results are needed quickly. Head Trauma-Child CTA Head Although late post-traumatic vascular complications, such as pseudoaneurysm, can occur, there is no substantial literature or expert consensus supporting the use of CTA in children in chronic traumatic injury. Imaging for vascular injury is primarily guided by clinical suspicion or imaging findings, such as fracture through the skull base or vascular channels. In these instances, CTA provides high spatial resolution and rapid assessment for vascular injury. MRA Head Although late post-traumatic vascular complications, such as pseudoaneurysm, can occur, there is no substantial literature or expert consensus supporting the use of MRA in children in chronic traumatic injury. Imaging for vascular injury is primarily guided by clinical suspicion or imaging findings, such as fracture through the skull base or vascular channels. MRA can be performed without IV contrast using time-of-flight sequences, although contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Arteriography Cerebral There is no relevant literature or expert consensus regarding the use of conventional cerebral angiography in evaluating children with chronic head trauma. FDG-PET/CT Brain There is no relevant literature or expert consensus regarding the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT of the brain in evaluating children with chronic head trauma. | Head Trauma Child PCAs. A few studies addressing CT is this setting support a low diagnostic yield for imaging in the post-traumatic setting [46,47]. One study of 52 children with chronic head injury demonstrated CTs performed on only 8 patients [46]. One patient was found to have a fracture. No intracranial injury was detected. CT has limited sensitivity for nonacute intracranial hemorrhage and small contusions. CT likely has little role in evaluating most children with chronic head injury but may be a consideration when results are needed quickly. Head Trauma-Child CTA Head Although late post-traumatic vascular complications, such as pseudoaneurysm, can occur, there is no substantial literature or expert consensus supporting the use of CTA in children in chronic traumatic injury. Imaging for vascular injury is primarily guided by clinical suspicion or imaging findings, such as fracture through the skull base or vascular channels. In these instances, CTA provides high spatial resolution and rapid assessment for vascular injury. MRA Head Although late post-traumatic vascular complications, such as pseudoaneurysm, can occur, there is no substantial literature or expert consensus supporting the use of MRA in children in chronic traumatic injury. Imaging for vascular injury is primarily guided by clinical suspicion or imaging findings, such as fracture through the skull base or vascular channels. MRA can be performed without IV contrast using time-of-flight sequences, although contrast may be helpful for clarification in some instances, particularly when imaging is limited by tortuosity or flow artifact. Arteriography Cerebral There is no relevant literature or expert consensus regarding the use of conventional cerebral angiography in evaluating children with chronic head trauma. FDG-PET/CT Brain There is no relevant literature or expert consensus regarding the use of fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)-PET/CT of the brain in evaluating children with chronic head trauma. | 3083021 |
acrac_3083021_10 | Head Trauma Child PCAs | MR Spectroscopy Head There have been few studies investigating spectroscopic changes in the brain of children with prior head trauma. Some preliminary data suggest there may be reduced N-acetyl aspartate metabolites in the corpus callosum in these children [50]. However, these studies are limited by patient selection and very small sample size, and the clinical relevance of these findings in children is unclear. MRI Head without IV Contrast with DTI There have been a few studies suggesting that post-traumatic microstructural changes in the white matter can be identified with diffusion-tensor imaging (DTI). However, these studies are usually in older adolescents and young adults, and the data remain limited by small sample sizes in select populations. There are little data regarding the routine use of this technique in children. MRI Functional (fMRI) Head without IV Contrast Some preliminary work suggests that changes in connectivity in pediatric patients may correlate with postconcussion symptoms [51,52]. However, studies are limited by small, select sample sizes, and there remains no strong literature to support the routine use of functional MRI (fMRI) in evaluation of post-traumatic head injury. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging | Head Trauma Child PCAs. MR Spectroscopy Head There have been few studies investigating spectroscopic changes in the brain of children with prior head trauma. Some preliminary data suggest there may be reduced N-acetyl aspartate metabolites in the corpus callosum in these children [50]. However, these studies are limited by patient selection and very small sample size, and the clinical relevance of these findings in children is unclear. MRI Head without IV Contrast with DTI There have been a few studies suggesting that post-traumatic microstructural changes in the white matter can be identified with diffusion-tensor imaging (DTI). However, these studies are usually in older adolescents and young adults, and the data remain limited by small sample sizes in select populations. There are little data regarding the routine use of this technique in children. MRI Functional (fMRI) Head without IV Contrast Some preliminary work suggests that changes in connectivity in pediatric patients may correlate with postconcussion symptoms [51,52]. However, studies are limited by small, select sample sizes, and there remains no strong literature to support the routine use of functional MRI (fMRI) in evaluation of post-traumatic head injury. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www. acr.org/ac. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging | 3083021 |
acrac_3082580_0 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Introduction/Background Nonischemic cardiomyopathies (NICMs) encompass a broad spectrum of disorders of the myocardium associated with mechanical or electrical dysfunction leading to inappropriate ventricular hypertrophy or dilation, without evidence of ischemia [1]. Generally, valvular, hypertensive, and congenital diseases are treated separately from the NICM discussed here. The myocardial involvement can be either primary (genetic, acquired, or mixed) or secondary to a systemic disease process [2]. NICM can also be classified into distinct morphological and functional types, each of which can be subclassified as familial or nonfamilial types [3]. In this document, we have adapted this classification with five variants of nonischemic myocardial diseases: 1) hypertrophic cardiomyopathy (HCM); 2) restrictive cardiomyopathy or infiltrative diseases; 3) dilated cardiomyopathy (DCM) or unclassified cardiomyopathy; 4) arrhythmogenic cardiomyopathy (arrhythmia of ventricular origin); and 5) inflammatory cardiomyopathy [2]. With increasing availability and use of genetics, it is now known that cardiomyopathies do not fit into specific morphological and functional phenotypes as discussed above, and there is tremendous genetic heterogeneity. The recently proposed MOGE(S) nosology system provides a more comprehensive classification of cardiomyopathies, describing the morphofunctional phenotype (M), organ (O), genetic inheritance pattern (G), etiological annotation (E), and functional status (S) [4]. NICM has an approximate prevalence of 0.02% with an annual death rate of 25,000 in the United States [2]. In adults, the prevalence of HCM is 1:250 to 500, DCM is 1:250 to 500, and arrhythmogenic right ventricular cardiomyopathy (ARVD) is 1:2,000 to 5,000 [5], whereas these are uncommon in children. Clinical presentation is variable, including heart failure (HF), arrhythmia, sudden death, and acute chest pain. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Introduction/Background Nonischemic cardiomyopathies (NICMs) encompass a broad spectrum of disorders of the myocardium associated with mechanical or electrical dysfunction leading to inappropriate ventricular hypertrophy or dilation, without evidence of ischemia [1]. Generally, valvular, hypertensive, and congenital diseases are treated separately from the NICM discussed here. The myocardial involvement can be either primary (genetic, acquired, or mixed) or secondary to a systemic disease process [2]. NICM can also be classified into distinct morphological and functional types, each of which can be subclassified as familial or nonfamilial types [3]. In this document, we have adapted this classification with five variants of nonischemic myocardial diseases: 1) hypertrophic cardiomyopathy (HCM); 2) restrictive cardiomyopathy or infiltrative diseases; 3) dilated cardiomyopathy (DCM) or unclassified cardiomyopathy; 4) arrhythmogenic cardiomyopathy (arrhythmia of ventricular origin); and 5) inflammatory cardiomyopathy [2]. With increasing availability and use of genetics, it is now known that cardiomyopathies do not fit into specific morphological and functional phenotypes as discussed above, and there is tremendous genetic heterogeneity. The recently proposed MOGE(S) nosology system provides a more comprehensive classification of cardiomyopathies, describing the morphofunctional phenotype (M), organ (O), genetic inheritance pattern (G), etiological annotation (E), and functional status (S) [4]. NICM has an approximate prevalence of 0.02% with an annual death rate of 25,000 in the United States [2]. In adults, the prevalence of HCM is 1:250 to 500, DCM is 1:250 to 500, and arrhythmogenic right ventricular cardiomyopathy (ARVD) is 1:2,000 to 5,000 [5], whereas these are uncommon in children. Clinical presentation is variable, including heart failure (HF), arrhythmia, sudden death, and acute chest pain. | 3082580 |
acrac_3082580_1 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Common presentations include dyspnea, edema, ascites, chest discomfort palpitations, and syncope. In patients with clinical HF, a primary cardiomyopathy is diagnosed in 2% to 15% of patients, whereas in some large-scale trials, patients with nonischemic HF accounted for 18% to 53% of the study population [6]. Acute presentation with chest pain, elevated cardiac enzymes, and abnormal electrocardiogram (ECG) may be seen inflammatory cardiomyopathies. Unlike ischemic cardiomyopathy, the pathophysiology of NICM is usually unclear and multifactorial, the functional consequences are global, the prognosis is better, and the therapeutic response is different [2]. The primary role of imaging in NICM is to characterize the disease and establish the specific etiology, which is essential for determining optimal management. Although patients with NICM require general treatment for HF or arrhythmia, therapy is often tailored, depending on the etiology. For example, iron-overload cardiomyopathy is aMayo Clinic, Rochester, Minnesota. bPanel Chair, Cleveland Clinic Florida, Weston, Florida. cPanel Vice-Chair, Cleveland Clinic, Cleveland, Ohio. dMiami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida. eUniversity of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah. fUniversity of Wisconsin, Madison, Wisconsin. gUniversity of Iowa Hospitals and Clinics, Iowa City, Iowa. hToronto General Hospital, University of Toronto, Toronto, Ontario, Canada. iThe Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. jQueen's University, Kingston, Ontario, Canada; Cardiology expert. kNorthwestern University Feinberg School of Medicine, Chicago, Illinois; Society for Cardiovascular Magnetic Resonance. lUniversity of Alabama at Birmingham, Birmingham, Alabama. mUniversity of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Common presentations include dyspnea, edema, ascites, chest discomfort palpitations, and syncope. In patients with clinical HF, a primary cardiomyopathy is diagnosed in 2% to 15% of patients, whereas in some large-scale trials, patients with nonischemic HF accounted for 18% to 53% of the study population [6]. Acute presentation with chest pain, elevated cardiac enzymes, and abnormal electrocardiogram (ECG) may be seen inflammatory cardiomyopathies. Unlike ischemic cardiomyopathy, the pathophysiology of NICM is usually unclear and multifactorial, the functional consequences are global, the prognosis is better, and the therapeutic response is different [2]. The primary role of imaging in NICM is to characterize the disease and establish the specific etiology, which is essential for determining optimal management. Although patients with NICM require general treatment for HF or arrhythmia, therapy is often tailored, depending on the etiology. For example, iron-overload cardiomyopathy is aMayo Clinic, Rochester, Minnesota. bPanel Chair, Cleveland Clinic Florida, Weston, Florida. cPanel Vice-Chair, Cleveland Clinic, Cleveland, Ohio. dMiami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida. eUniversity of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah. fUniversity of Wisconsin, Madison, Wisconsin. gUniversity of Iowa Hospitals and Clinics, Iowa City, Iowa. hToronto General Hospital, University of Toronto, Toronto, Ontario, Canada. iThe Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada. jQueen's University, Kingston, Ontario, Canada; Cardiology expert. kNorthwestern University Feinberg School of Medicine, Chicago, Illinois; Society for Cardiovascular Magnetic Resonance. lUniversity of Alabama at Birmingham, Birmingham, Alabama. mUniversity of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography. | 3082580 |
acrac_3082580_2 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | nWisconsin Heart Hospital, Milwaukee, Wisconsin; Nuclear cardiology expert. oJohns Hopkins Medical Institute, Baltimore, Maryland. pSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. Reprint requests to: [email protected] Nonischemic Myocardial Disease treated with chelation therapy; cardiac sarcoidosis is treated with high-dose corticosteroids; cardiac amyloidosis is treated with chemotherapy for light-chain amyloidosis (AL type) and novel therapies for transthyretin type; Fabry disease is treated with enzyme replacement therapy; and severe HCM or endomyocardial fibrosis is treated with surgery [2]. An endomyocardial biopsy may be required for definitive diagnosis in some cases; however, it is an invasive procedure and the yield may be low because of the patchy nature of disease processes. In unexplained cardiomyopathy, the final diagnosis based on biopsy differed from initial diagnosis in 31% of patients, and endomyocardial biopsy made the final diagnosis in 75% of these cases [9]. Imaging is also helpful for quantification of the disease process, risk stratification, prognosis, and monitoring response to therapy. 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. Chest Radiography Chest radiography can provide information on HF and vascular abnormalities; however, there is no specific role for radiography in characterizing the different types of NICM. Echocardiography Echocardiography provides information on ventricular function (global/regional, systolic/diastolic), volumes, mass, thickness, as well as valvular function. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . nWisconsin Heart Hospital, Milwaukee, Wisconsin; Nuclear cardiology expert. oJohns Hopkins Medical Institute, Baltimore, Maryland. pSpecialty Chair, UT Southwestern Medical Center, Dallas, Texas. Reprint requests to: [email protected] Nonischemic Myocardial Disease treated with chelation therapy; cardiac sarcoidosis is treated with high-dose corticosteroids; cardiac amyloidosis is treated with chemotherapy for light-chain amyloidosis (AL type) and novel therapies for transthyretin type; Fabry disease is treated with enzyme replacement therapy; and severe HCM or endomyocardial fibrosis is treated with surgery [2]. An endomyocardial biopsy may be required for definitive diagnosis in some cases; however, it is an invasive procedure and the yield may be low because of the patchy nature of disease processes. In unexplained cardiomyopathy, the final diagnosis based on biopsy differed from initial diagnosis in 31% of patients, and endomyocardial biopsy made the final diagnosis in 75% of these cases [9]. Imaging is also helpful for quantification of the disease process, risk stratification, prognosis, and monitoring response to therapy. 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. Chest Radiography Chest radiography can provide information on HF and vascular abnormalities; however, there is no specific role for radiography in characterizing the different types of NICM. Echocardiography Echocardiography provides information on ventricular function (global/regional, systolic/diastolic), volumes, mass, thickness, as well as valvular function. | 3082580 |
acrac_3082580_3 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | The morphology can be assessed, although it is limited in the evaluation of the right ventricle (RV). With the use of advanced techniques such as 3-D echocardiography, further subtyping of NICM is possible. Myocardial deformation can be evaluated using tissue Doppler imaging and speckle-tracking (2-D or 3-D). Abnormal global longitudinal strain enables detection of subclinical left ventricle (LV) dysfunction in several disease entities [11]. Doppler metrics are useful in evaluation of diastolic dysfunction, especially in restrictive cardiomyopathies and HCM [12]. However, routine echocardiography does not have tissue characterization capabilities. Contrast echocardiography can be used in the quantification of ventricular volumes and EF as well as regional wall motion when the routine images are suboptimal. It is also used in the evaluation of noncompaction, thrombus aneurysm, and apical lesions such as apical variant HCM, stress-induced cardiomyopathy, and endocardial fibroelastosis [13]. Cardiac CT Coronary CTA has a limited role in the evaluation of NICM, predominantly for excluding coronary artery disease (CAD) as the etiology of HF [15]. Cardiac CT can be used in the evaluation of morphology, characterization, and quantification of function in patients when echocardiography is suboptimal because of poor acoustic windows and MRI is suboptimal because of artifacts. The function and volumes obtained from CT correlate with other Nonischemic Myocardial Disease modalities including MRI [16,17]. With retrospective ECG-gated acquisition, dynamic and functional information can be obtained. First-pass myocardial perfusion can be used to evaluate for ischemia. Delayed iodine- enhancement imaging can show variable patterns of enhancement in NICM, albeit at a lower contrast-to-noise ratio compared with MRI. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . The morphology can be assessed, although it is limited in the evaluation of the right ventricle (RV). With the use of advanced techniques such as 3-D echocardiography, further subtyping of NICM is possible. Myocardial deformation can be evaluated using tissue Doppler imaging and speckle-tracking (2-D or 3-D). Abnormal global longitudinal strain enables detection of subclinical left ventricle (LV) dysfunction in several disease entities [11]. Doppler metrics are useful in evaluation of diastolic dysfunction, especially in restrictive cardiomyopathies and HCM [12]. However, routine echocardiography does not have tissue characterization capabilities. Contrast echocardiography can be used in the quantification of ventricular volumes and EF as well as regional wall motion when the routine images are suboptimal. It is also used in the evaluation of noncompaction, thrombus aneurysm, and apical lesions such as apical variant HCM, stress-induced cardiomyopathy, and endocardial fibroelastosis [13]. Cardiac CT Coronary CTA has a limited role in the evaluation of NICM, predominantly for excluding coronary artery disease (CAD) as the etiology of HF [15]. Cardiac CT can be used in the evaluation of morphology, characterization, and quantification of function in patients when echocardiography is suboptimal because of poor acoustic windows and MRI is suboptimal because of artifacts. The function and volumes obtained from CT correlate with other Nonischemic Myocardial Disease modalities including MRI [16,17]. With retrospective ECG-gated acquisition, dynamic and functional information can be obtained. First-pass myocardial perfusion can be used to evaluate for ischemia. Delayed iodine- enhancement imaging can show variable patterns of enhancement in NICM, albeit at a lower contrast-to-noise ratio compared with MRI. | 3082580 |
acrac_3082580_4 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Similar to MRI, extracellular volume (ECV) can be quantified with CT either using a single- or dual-energy CT technique [18]. CT strain imaging to quantify regional function [19] and CT evaluation of diastolic function are not routinely used in clinical practice [20]. Coronary calcium score is used for risk stratification of CAD in asymptomatic patients and does not have a specific role in evaluation of NICM. Coronary Arteriography Coronary arteriography is used to evaluate CAD as a cause of HF, especially in high-risk patients. Right and left heart catheterizations are useful in pulmonary hypertension, providing cardiac hemodynamics and prognostic value. Right heart and simultaneous right and left heart catheterization is useful in distinguishing restrictive cardiomyopathies from constrictive pericarditis [31]. A ventriculogram can be used to evaluate associated regional wall motion abnormalities (RWMA). Endomyocardial biopsy is used to establish etiology in cases that are indeterminate after imaging. Discussion of Procedures by Variant Variant 1: Suspected hypertrophic cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. HCM is an inherited myocardial hypertrophy with heterogeneous phenotypic expression (asymmetric septal, apical, mid ventricular, lateral wall, mass-like, and concentric types) [32]. Patients with HCM can present with diastolic dysfunction, LV outflow tract (LVOT) obstruction, ischemic chest pain, arrhythmias, or sudden cardiac death [33]. Occasionally, clinical symptoms are produced by papillary muscle abnormalities (anomalous chordal attachment to the base of anterior leaflet, double bifid muscles, apical displacement, hypermobility, elongated anterior mitral leaflet) without significant myocardial hypertrophy [34]. Asymptomatic family members of HCM often undergo imaging as a screening test. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Similar to MRI, extracellular volume (ECV) can be quantified with CT either using a single- or dual-energy CT technique [18]. CT strain imaging to quantify regional function [19] and CT evaluation of diastolic function are not routinely used in clinical practice [20]. Coronary calcium score is used for risk stratification of CAD in asymptomatic patients and does not have a specific role in evaluation of NICM. Coronary Arteriography Coronary arteriography is used to evaluate CAD as a cause of HF, especially in high-risk patients. Right and left heart catheterizations are useful in pulmonary hypertension, providing cardiac hemodynamics and prognostic value. Right heart and simultaneous right and left heart catheterization is useful in distinguishing restrictive cardiomyopathies from constrictive pericarditis [31]. A ventriculogram can be used to evaluate associated regional wall motion abnormalities (RWMA). Endomyocardial biopsy is used to establish etiology in cases that are indeterminate after imaging. Discussion of Procedures by Variant Variant 1: Suspected hypertrophic cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. HCM is an inherited myocardial hypertrophy with heterogeneous phenotypic expression (asymmetric septal, apical, mid ventricular, lateral wall, mass-like, and concentric types) [32]. Patients with HCM can present with diastolic dysfunction, LV outflow tract (LVOT) obstruction, ischemic chest pain, arrhythmias, or sudden cardiac death [33]. Occasionally, clinical symptoms are produced by papillary muscle abnormalities (anomalous chordal attachment to the base of anterior leaflet, double bifid muscles, apical displacement, hypermobility, elongated anterior mitral leaflet) without significant myocardial hypertrophy [34]. Asymptomatic family members of HCM often undergo imaging as a screening test. | 3082580 |
acrac_3082580_5 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of HCM. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography with ventriculography for the evaluation of HCM. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of HCM. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of HCM. CT Heart Function and Morphology Cardiac CT can be used in the evaluation of morphology and function in patients with suboptimal echocardiography. CT can provide accurate measurements of myocardial thickness. Myocardial fibrosis can be demonstrated and quantified in delayed-enhancement images with substantial agreement with MRI [36-38]. CTA Coronary There is no relevant literature to support the use of CTA in the evaluation of HCM when ischemic cardiomyopathy has already been excluded. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT heart for the evaluation of HCM. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of HCM. MRI Heart Function and Morphology MRI provides comprehensive information for the evaluation of HCM, including the morphology, location, distribution, and extent of hypertrophy and fibrosis [39]. MRI is superior to echocardiography in recognizing areas of segmental hypertrophy, which may be missed or underestimated with echocardiography, particularly the LV apex, the RV anterior free wall, and the LV inferoseptum [39,40]. RV hypertrophy is seen in a third of Nonischemic Myocardial Disease patients [40]. MRI is more accurate than echocardiography in quantifying the myocardial thickness, which is an important prognostic indicator for myectomy [39]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of HCM. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography with ventriculography for the evaluation of HCM. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of HCM. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of HCM. CT Heart Function and Morphology Cardiac CT can be used in the evaluation of morphology and function in patients with suboptimal echocardiography. CT can provide accurate measurements of myocardial thickness. Myocardial fibrosis can be demonstrated and quantified in delayed-enhancement images with substantial agreement with MRI [36-38]. CTA Coronary There is no relevant literature to support the use of CTA in the evaluation of HCM when ischemic cardiomyopathy has already been excluded. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT heart for the evaluation of HCM. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of HCM. MRI Heart Function and Morphology MRI provides comprehensive information for the evaluation of HCM, including the morphology, location, distribution, and extent of hypertrophy and fibrosis [39]. MRI is superior to echocardiography in recognizing areas of segmental hypertrophy, which may be missed or underestimated with echocardiography, particularly the LV apex, the RV anterior free wall, and the LV inferoseptum [39,40]. RV hypertrophy is seen in a third of Nonischemic Myocardial Disease patients [40]. MRI is more accurate than echocardiography in quantifying the myocardial thickness, which is an important prognostic indicator for myectomy [39]. | 3082580 |
acrac_3082580_6 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | LVOT obstruction (seen in one-third of patients with HCM and provocable in another third), systolic anterior motion of the mitral valve and mitral regurgitation may be seen in asymmetric basal septal type of HCM [33], although the quantification of flow acceleration due to LVOT obstruction is inferior when using MRI compared with echocardiography. MRI also helps in risk stratification and identification of patients who will benefit from primary prevention with ICD, primarily by the use of LGE. LGE is seen in up to 50% to 80% of HCM patients, with the extent of LGE correlating directly with adverse prognosis [39]. HCM patients with LGE have a 7-fold risk for nonsustained ventricular tachycardia, and extensive LGE >15% of LV mass is a marker for sudden death [39]. Apical aneurysm and massive hypertrophy >30 mm are also high-risk factors for sudden cardiac death [39]. Elevated native T1 and ECV measurements may be seen in HCM. One study showed that native T1 has 100% sensitivity, 96% specificity, and 98% accuracy in distinguishing healthy from diseased myocardium, including HCM [41,42]. Another advantage of MRI is its ability to evaluate papillary muscle abnormalities, which require different surgical management [34,43]. MRI is also useful in follow-up after treatment such as myectomy or septal ablation. MRI is used to screen family members with myocardial crypts, elongated mitral leaflets, delayed relaxation, high EF, and LGE seen in gene-positive, phenotype-negative patients [40]. Anderson-Fabry disease presents with concentric LV thickening but may occasionally be asymmetric. Mid myocardial or subepicardial LGE is seen in the basal inferolateral segment of the LV, unlike HCM, wherein LGE is seen anywhere. There is no systolic anterior motion of the mitral valve or LVOT obstruction in Anderson-Fabry disease [35]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . LVOT obstruction (seen in one-third of patients with HCM and provocable in another third), systolic anterior motion of the mitral valve and mitral regurgitation may be seen in asymmetric basal septal type of HCM [33], although the quantification of flow acceleration due to LVOT obstruction is inferior when using MRI compared with echocardiography. MRI also helps in risk stratification and identification of patients who will benefit from primary prevention with ICD, primarily by the use of LGE. LGE is seen in up to 50% to 80% of HCM patients, with the extent of LGE correlating directly with adverse prognosis [39]. HCM patients with LGE have a 7-fold risk for nonsustained ventricular tachycardia, and extensive LGE >15% of LV mass is a marker for sudden death [39]. Apical aneurysm and massive hypertrophy >30 mm are also high-risk factors for sudden cardiac death [39]. Elevated native T1 and ECV measurements may be seen in HCM. One study showed that native T1 has 100% sensitivity, 96% specificity, and 98% accuracy in distinguishing healthy from diseased myocardium, including HCM [41,42]. Another advantage of MRI is its ability to evaluate papillary muscle abnormalities, which require different surgical management [34,43]. MRI is also useful in follow-up after treatment such as myectomy or septal ablation. MRI is used to screen family members with myocardial crypts, elongated mitral leaflets, delayed relaxation, high EF, and LGE seen in gene-positive, phenotype-negative patients [40]. Anderson-Fabry disease presents with concentric LV thickening but may occasionally be asymmetric. Mid myocardial or subepicardial LGE is seen in the basal inferolateral segment of the LV, unlike HCM, wherein LGE is seen anywhere. There is no systolic anterior motion of the mitral valve or LVOT obstruction in Anderson-Fabry disease [35]. | 3082580 |
acrac_3082580_7 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Low native T1 values are seen in Fabry disease because of sphingolipid deposition, often prior to the onset of structural and functional abnormalities [44]. With development of fibrosis, long native T1 and elevated ECV values can be seen. High T2 values, RV involvement, valve thickening, and lower global longitudinal strain can also be seen [45]. Danon disease also shows concentric LV thickening with edema and stress perfusion defect. LGE is usually in a mid myocardial distribution, less often in a subendocardial and transmural pattern in anterolateral and inferior segments of the LV, often with sparing of septum [46,47]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of HCM. MRI Heart Vasodilator Stress Reduced myocardial perfusion due to microvascular dysfunction is a poor prognostic factor in HCM. This may be seen even in areas without LGE, both in adults and children [48,49]. There is no evidence to support the use of MRI heart vasodilator stress for the evaluation of HCM when ischemic cardiomyopathy has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography for the evaluation of HCM. Echocardiography Transthoracic Resting Echocardiography is usually the initial imaging test in most patients with HCM. It is used in the evaluation of morphology, distribution, and quantification of HCM. Contrast echocardiography improves characterization of apical type of HCM [50]. Echocardiography is the preferred technique for the quantification of LVOT pressure gradient, which is a factor in selecting patients for myomectomy, as well as the assessment of systolic anterior motion, mitral regurgitation, and papillary muscle abnormalities. It can quantify LV systolic function, diastolic function, and left atrial volume. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Low native T1 values are seen in Fabry disease because of sphingolipid deposition, often prior to the onset of structural and functional abnormalities [44]. With development of fibrosis, long native T1 and elevated ECV values can be seen. High T2 values, RV involvement, valve thickening, and lower global longitudinal strain can also be seen [45]. Danon disease also shows concentric LV thickening with edema and stress perfusion defect. LGE is usually in a mid myocardial distribution, less often in a subendocardial and transmural pattern in anterolateral and inferior segments of the LV, often with sparing of septum [46,47]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of HCM. MRI Heart Vasodilator Stress Reduced myocardial perfusion due to microvascular dysfunction is a poor prognostic factor in HCM. This may be seen even in areas without LGE, both in adults and children [48,49]. There is no evidence to support the use of MRI heart vasodilator stress for the evaluation of HCM when ischemic cardiomyopathy has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography for the evaluation of HCM. Echocardiography Transthoracic Resting Echocardiography is usually the initial imaging test in most patients with HCM. It is used in the evaluation of morphology, distribution, and quantification of HCM. Contrast echocardiography improves characterization of apical type of HCM [50]. Echocardiography is the preferred technique for the quantification of LVOT pressure gradient, which is a factor in selecting patients for myomectomy, as well as the assessment of systolic anterior motion, mitral regurgitation, and papillary muscle abnormalities. It can quantify LV systolic function, diastolic function, and left atrial volume. | 3082580 |
acrac_3082580_8 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Decreased myocardial strain can be identified using speckle-tracking echocardiography [50]. Stress maneuvers, including a Valsalva maneuver in sitting, semisupine, and standing Nonischemic Myocardial Disease positions can be used to provoke LVOT gradients that may not be seen in resting states [51]. It is also the first- line test for screening, such as in the risk assessment of sudden cardiac death in competitive athletes [50]. Echocardiography Transthoracic Stress Exercise stress echo is used to assess provocable LVOT gradient if resting gradient is not severe. It is also useful in the assessment of worsening mitral regurgitation [51]. Variant 2: Suspected restrictive cardiomyopathy or infiltrative disease. Ischemic cardiomyopathy already excluded. Initial imaging. Infiltrative disease is characterized by deposition of abnormal substances in the myocardium, resulting in myocardial thickening or dilation and restricted ventricular filling. Amyloidosis, Anderson-Fabry disease, acute sarcoidosis, Danon disease, endomyocardial fibrosis, oxalosis, mucopolysaccharidoses, and Friedrich ataxia result in myocardial thickening, whereas chronic sarcoidosis, scleroderma, and iron overload result in myocardial thinning [52]. Cardiac amyloidosis is usually of AL type or transthyretin-related amyloidosis (ATTR type), resulting in myocardial and valvular thickening and presenting with HF or arrhythmia. Myocardial involvement occurs in 25% of patients with systemic sarcoidosis in the United States [53]. Cardiac sarcoidosis is characterized by myocardial infiltration with noncaseating granulomas and presents with conduction abnormalities, arrhythmias, sudden cardiac death, HF, pericardial effusion, or ventricular aneurysms [2]. Diagnosis is based on the Japanese Ministry of Health and Welfare guidelines [54] or expert consensus recommendations [55]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Decreased myocardial strain can be identified using speckle-tracking echocardiography [50]. Stress maneuvers, including a Valsalva maneuver in sitting, semisupine, and standing Nonischemic Myocardial Disease positions can be used to provoke LVOT gradients that may not be seen in resting states [51]. It is also the first- line test for screening, such as in the risk assessment of sudden cardiac death in competitive athletes [50]. Echocardiography Transthoracic Stress Exercise stress echo is used to assess provocable LVOT gradient if resting gradient is not severe. It is also useful in the assessment of worsening mitral regurgitation [51]. Variant 2: Suspected restrictive cardiomyopathy or infiltrative disease. Ischemic cardiomyopathy already excluded. Initial imaging. Infiltrative disease is characterized by deposition of abnormal substances in the myocardium, resulting in myocardial thickening or dilation and restricted ventricular filling. Amyloidosis, Anderson-Fabry disease, acute sarcoidosis, Danon disease, endomyocardial fibrosis, oxalosis, mucopolysaccharidoses, and Friedrich ataxia result in myocardial thickening, whereas chronic sarcoidosis, scleroderma, and iron overload result in myocardial thinning [52]. Cardiac amyloidosis is usually of AL type or transthyretin-related amyloidosis (ATTR type), resulting in myocardial and valvular thickening and presenting with HF or arrhythmia. Myocardial involvement occurs in 25% of patients with systemic sarcoidosis in the United States [53]. Cardiac sarcoidosis is characterized by myocardial infiltration with noncaseating granulomas and presents with conduction abnormalities, arrhythmias, sudden cardiac death, HF, pericardial effusion, or ventricular aneurysms [2]. Diagnosis is based on the Japanese Ministry of Health and Welfare guidelines [54] or expert consensus recommendations [55]. | 3082580 |
acrac_3082580_9 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Siderotic cardiomyopathy is characterized by iron deposition from frequent blood transfusions and altered iron hemostasis in hemoglobinopathy patients. Siderotic cardiomyopathy presents in advanced stages with HF, conduction abnormalities, or sudden death [2]. Scleroderma involves the heart in 80% (in autopsy) of cases, manifesting as HF, arrhythmia, CAD, peripheral vascular disease, or sudden death [2]. Endomyocardial fibrosis (Loeffler endocarditis in nontropical regions) is a spectrum of hyperesoinophlic syndrome (eosinophils >1,500/mm3; >6 months), with cardiac involvement seen in 50% of these patients [56]. There is an early necrotic phase followed by thrombotic and fibrotic phases. Myocardial oxalosis presents with LV thickening, heart block, and conduction abnormalities. Friedreich ataxia is characterized by mitochondrial iron accumulation, with cardiomyopathy seen in 63% of these patients [52]. Mucopolysaccharidoses has variable phenotypic expression. Infiltrative disease is generally evaluated with history, clinical examination, ECG, serology, and imaging tests [52]. Endomyocardial biopsy may be ultimately required for definitive diagnosis. Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of restrictive cardiomyopathy. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography with ventriculography for infiltrative cardiac diseases. Right heart catheterization is used for the evaluation of hemodynamics, which is useful in the diagnosis of pulmonary hypertension and has prognostic value. In addition, right and left heart catheterization can be used to evaluate for constrictive pericarditis, which often has to be distinguished from restrictive cardiomyopathy. CT Chest There is no relevant literature to support the use of CT chest for evaluation of restrictive cardiomyopathy. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Siderotic cardiomyopathy is characterized by iron deposition from frequent blood transfusions and altered iron hemostasis in hemoglobinopathy patients. Siderotic cardiomyopathy presents in advanced stages with HF, conduction abnormalities, or sudden death [2]. Scleroderma involves the heart in 80% (in autopsy) of cases, manifesting as HF, arrhythmia, CAD, peripheral vascular disease, or sudden death [2]. Endomyocardial fibrosis (Loeffler endocarditis in nontropical regions) is a spectrum of hyperesoinophlic syndrome (eosinophils >1,500/mm3; >6 months), with cardiac involvement seen in 50% of these patients [56]. There is an early necrotic phase followed by thrombotic and fibrotic phases. Myocardial oxalosis presents with LV thickening, heart block, and conduction abnormalities. Friedreich ataxia is characterized by mitochondrial iron accumulation, with cardiomyopathy seen in 63% of these patients [52]. Mucopolysaccharidoses has variable phenotypic expression. Infiltrative disease is generally evaluated with history, clinical examination, ECG, serology, and imaging tests [52]. Endomyocardial biopsy may be ultimately required for definitive diagnosis. Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of restrictive cardiomyopathy. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography with ventriculography for infiltrative cardiac diseases. Right heart catheterization is used for the evaluation of hemodynamics, which is useful in the diagnosis of pulmonary hypertension and has prognostic value. In addition, right and left heart catheterization can be used to evaluate for constrictive pericarditis, which often has to be distinguished from restrictive cardiomyopathy. CT Chest There is no relevant literature to support the use of CT chest for evaluation of restrictive cardiomyopathy. | 3082580 |
acrac_3082580_10 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | CT chest may show mediastinal lymphadenopathy and lung changes in systemic sarcoidosis. Pericardial calcification points toward a pericardial constriction rather than restrictive cardiomyopathy. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of restrictive cardiomyopathy. Incidental pericardial calcification points toward a pericardial constriction rather than restrictive cardiomyopathy. CT Heart Function and Morphology Abnormal first-pass perfusion, delayed iodine enhancement, and high ECV values have been shown with CT in cardiac amyloidosis [57,58]. Subepicardial or mid myocardial delayed iodine enhancement has also been shown to identify cardiac sarcoidosis [59]. Pericardial calcification points toward a pericardial constriction rather than restrictive cardiomyopathy. Nonischemic Myocardial Disease CTA Coronary There is no relevant literature to support the use of coronary CTA for the evaluation of restrictive cardiomyopathy when ischemic cardiomyopathy has already been excluded. Nuclear Medicine Tc-DPD and Tc-PYP have high specificity in the diagnosis of cardiac amyloidosis. Ga-67 scintigraphy shows high uptake in cardiac sarcoidosis, with the intensity correlating with degree of inflammation [55]; however, it has low sensitivity [55]. Perfusion defects seen in thallium-201 and Tc-99m myocardial scintigraphy, as well as Rb- 82, can be distinguished from ischemia by using PET/CT [55]. FDG-PET/CT Heart FDG-PET performed after suppressing normal glucose metabolism shows high uptake in cardiac sarcoidosis, with reverse distribution in thallium-201 scans. FDG-PET had an 82% to 100% specificity and 39% to 91% specificity in the diagnosis of cardiac sarcoidosis [54]. FDG has higher sensitivity than Ga-67 scintigraphy, although Ga-67 scintigraphy is included in the imaging criteria [54]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . CT chest may show mediastinal lymphadenopathy and lung changes in systemic sarcoidosis. Pericardial calcification points toward a pericardial constriction rather than restrictive cardiomyopathy. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of restrictive cardiomyopathy. Incidental pericardial calcification points toward a pericardial constriction rather than restrictive cardiomyopathy. CT Heart Function and Morphology Abnormal first-pass perfusion, delayed iodine enhancement, and high ECV values have been shown with CT in cardiac amyloidosis [57,58]. Subepicardial or mid myocardial delayed iodine enhancement has also been shown to identify cardiac sarcoidosis [59]. Pericardial calcification points toward a pericardial constriction rather than restrictive cardiomyopathy. Nonischemic Myocardial Disease CTA Coronary There is no relevant literature to support the use of coronary CTA for the evaluation of restrictive cardiomyopathy when ischemic cardiomyopathy has already been excluded. Nuclear Medicine Tc-DPD and Tc-PYP have high specificity in the diagnosis of cardiac amyloidosis. Ga-67 scintigraphy shows high uptake in cardiac sarcoidosis, with the intensity correlating with degree of inflammation [55]; however, it has low sensitivity [55]. Perfusion defects seen in thallium-201 and Tc-99m myocardial scintigraphy, as well as Rb- 82, can be distinguished from ischemia by using PET/CT [55]. FDG-PET/CT Heart FDG-PET performed after suppressing normal glucose metabolism shows high uptake in cardiac sarcoidosis, with reverse distribution in thallium-201 scans. FDG-PET had an 82% to 100% specificity and 39% to 91% specificity in the diagnosis of cardiac sarcoidosis [54]. FDG has higher sensitivity than Ga-67 scintigraphy, although Ga-67 scintigraphy is included in the imaging criteria [54]. | 3082580 |
acrac_3082580_11 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | A meta-analysis showed 89% sensitivity, 78% specificity, and area under the receiver operator characteristic curve of 93% for diagnosis of cardiac sarcoidosis [60]. The FDG activity can be quantified to improve the diagnostic accuracy, assess disease activity, and evaluate prognosis [60]. Simultaneous PET/MRI has been shown to be feasible with diagnostic image quality to evaluate cardiac sarcoidosis [61]. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of restrictive cardiomyopathy. MRI chest may show mediastinal lymphadenopathy and lung changes in systemic sarcoidosis. MRI Heart Function and Morphology MRI has distinctive appearances in several infiltrative disorders and restrictive cardiomyopathies. Cardiac amyloidosis produces concentric thickening of ventricles, atria, interatrial septum, and valves, with low signal in T2-weighted images [62]. Diffuse subendocardial LGE is seen in early stages, which progresses to transmural LGE. Abnormal LGE has a pooled specificity of 92% and sensitivity of 85% in the diagnosis of cardiac amyloidosis [63]. Dark blood pool and earlier nulling of myocardium is also seen in cardiac amyloidosis. High native T1 and ECV values are more sensitive than LGE and reliably distinguish amyloidosis from HCM [64]. MRI can distinguish AL and ATTR types, with ATTR amyloidosis showing more LV thickening and mass, lower left ventricular ejection fraction (LVEF), greater LGE, more transmural LGE, and lower T1 values than the AL type [64]. An LGE-based scoring system was shown to have 87% sensitivity and 96% specificity in distinguishing AL and ATTR amyloidosis [64]. LGE, T1, and ECV abnormalities all correlate with prognosis in cardiac amyloidosis [65]. Transmural LGE is a predictor of adverse events including death [66]. Postcontrast difference in T1 between subepicardium and subendocardium of >23 ms predicts mortality with high accuracy [67]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . A meta-analysis showed 89% sensitivity, 78% specificity, and area under the receiver operator characteristic curve of 93% for diagnosis of cardiac sarcoidosis [60]. The FDG activity can be quantified to improve the diagnostic accuracy, assess disease activity, and evaluate prognosis [60]. Simultaneous PET/MRI has been shown to be feasible with diagnostic image quality to evaluate cardiac sarcoidosis [61]. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of restrictive cardiomyopathy. MRI chest may show mediastinal lymphadenopathy and lung changes in systemic sarcoidosis. MRI Heart Function and Morphology MRI has distinctive appearances in several infiltrative disorders and restrictive cardiomyopathies. Cardiac amyloidosis produces concentric thickening of ventricles, atria, interatrial septum, and valves, with low signal in T2-weighted images [62]. Diffuse subendocardial LGE is seen in early stages, which progresses to transmural LGE. Abnormal LGE has a pooled specificity of 92% and sensitivity of 85% in the diagnosis of cardiac amyloidosis [63]. Dark blood pool and earlier nulling of myocardium is also seen in cardiac amyloidosis. High native T1 and ECV values are more sensitive than LGE and reliably distinguish amyloidosis from HCM [64]. MRI can distinguish AL and ATTR types, with ATTR amyloidosis showing more LV thickening and mass, lower left ventricular ejection fraction (LVEF), greater LGE, more transmural LGE, and lower T1 values than the AL type [64]. An LGE-based scoring system was shown to have 87% sensitivity and 96% specificity in distinguishing AL and ATTR amyloidosis [64]. LGE, T1, and ECV abnormalities all correlate with prognosis in cardiac amyloidosis [65]. Transmural LGE is a predictor of adverse events including death [66]. Postcontrast difference in T1 between subepicardium and subendocardium of >23 ms predicts mortality with high accuracy [67]. | 3082580 |
acrac_3082580_12 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Low T2 value and short T1 in >50% of myocardium T1 scout image are also poor prognostic factors [2]. MRI has sensitivity of 75% to 100% and specificity of 75% to 77% in the diagnosis of cardiac sarcoidosis [54,68,69]. In the acute stage, MRI shows wall thickening, high T2 signal (due to edema), high native T1 and T2 values, RWMA, and LGE. LGE is more common in the basal septal and lateral walls of the LV in a subepicardial or mid myocardial distribution. In the chronic stage, wall thinning, aneurysms, RWMA, and LGE may be seen (mid myocardial, subepicardial, and/or transmural) [70]. LGE correlates with prognosis with a hazard ratio of 32 for lethal events [71]. There is a good response to steroids in patients with lower LGE at initiation of therapy [72]. High native T1 and T2 values provide higher discriminatory accuracy compared with traditional criteria and help in evaluating the response to treatment [73]. Myocardial iron deposition can be reliably quantified using T2* techniques. Myocardial T2* <20 ms indicates significant iron deposition and <10 ms indicates advanced iron deposition with high accuracy [74]. T1-mapping is more reproducible and sensitive, with low T1 values seen in 32% of patients with normal T2* [75]. With appropriate use of chelation therapy, improvements in T2* and LVEF has been reported [76]. The use of MRI has resulted in improved outcomes with death rates declining to 2.3 per 1,000 compared with 7.9 per 1,000 prior to the use of MRI [76]. Linear mid myocardial LGE is seen in 66% of patients with scleroderma, either in the ventricular septum or the LV free wall at the basal and mid levels [77]. Patchy RV insertion enhancement can be seen in 17% of patients (76). LGE is more severe in patients with longer duration of Raynaud disease [78]. High native T1 and ECV values are seen in asymptomatic patients with no known cardiac involvement, due to inflammation, and are | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Low T2 value and short T1 in >50% of myocardium T1 scout image are also poor prognostic factors [2]. MRI has sensitivity of 75% to 100% and specificity of 75% to 77% in the diagnosis of cardiac sarcoidosis [54,68,69]. In the acute stage, MRI shows wall thickening, high T2 signal (due to edema), high native T1 and T2 values, RWMA, and LGE. LGE is more common in the basal septal and lateral walls of the LV in a subepicardial or mid myocardial distribution. In the chronic stage, wall thinning, aneurysms, RWMA, and LGE may be seen (mid myocardial, subepicardial, and/or transmural) [70]. LGE correlates with prognosis with a hazard ratio of 32 for lethal events [71]. There is a good response to steroids in patients with lower LGE at initiation of therapy [72]. High native T1 and T2 values provide higher discriminatory accuracy compared with traditional criteria and help in evaluating the response to treatment [73]. Myocardial iron deposition can be reliably quantified using T2* techniques. Myocardial T2* <20 ms indicates significant iron deposition and <10 ms indicates advanced iron deposition with high accuracy [74]. T1-mapping is more reproducible and sensitive, with low T1 values seen in 32% of patients with normal T2* [75]. With appropriate use of chelation therapy, improvements in T2* and LVEF has been reported [76]. The use of MRI has resulted in improved outcomes with death rates declining to 2.3 per 1,000 compared with 7.9 per 1,000 prior to the use of MRI [76]. Linear mid myocardial LGE is seen in 66% of patients with scleroderma, either in the ventricular septum or the LV free wall at the basal and mid levels [77]. Patchy RV insertion enhancement can be seen in 17% of patients (76). LGE is more severe in patients with longer duration of Raynaud disease [78]. High native T1 and ECV values are seen in asymptomatic patients with no known cardiac involvement, due to inflammation, and are | 3082580 |
acrac_3082580_13 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Nonischemic Myocardial Disease associated with low diastolic and systolic strain rates [78]. Focal edema and fibrosis are also seen. Pericarditis, pericardial effusion, and adhesions may be seen. In endomyocardial fibrosis, the apical wall is thickened and has a high T2 signal. A characteristic 3-layered pattern of LGE is seen with an inner layer of dark nonenhancing thrombus, middle layer of subendocardial LGE due to diffuse fibrosis (from LVOT to apex), and outer layer of nonenhancing normal myocardium [56,79]. LGE was associated with poor functional class and higher chance of surgery [56]. In Churg Strauss syndrome, LGE is seen in apical and mid segments and in anterior and anteroseptal segments in a subendocardial distribution. In myocardial oxalosis, concentric LV thickening and diastolic dysfunction are seen. In Friedreich ataxia, concentric or asymmetric LV thickening, diastolic dysfunction, and fibrosis may be seen. Mucopolysaccharidoses have variable expression, including asymmetric septal thickening, mitral or aortic valve pathologies, and normal EF [52]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of restrictive cardiomyopathy. Ischemia has already been excluded. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of restrictive cardiomyopathy. Ischemia has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echo for the evaluation of restrictive cardiomyopathy. Echocardiography Transthoracic Resting Echocardiography is often the initial imaging test that identifies possible restrictive cardiomyopathy. Echocardiography can evaluate diastolic function with high accuracy, which is often impaired in early stages of several restrictive cardiomyopathies. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Nonischemic Myocardial Disease associated with low diastolic and systolic strain rates [78]. Focal edema and fibrosis are also seen. Pericarditis, pericardial effusion, and adhesions may be seen. In endomyocardial fibrosis, the apical wall is thickened and has a high T2 signal. A characteristic 3-layered pattern of LGE is seen with an inner layer of dark nonenhancing thrombus, middle layer of subendocardial LGE due to diffuse fibrosis (from LVOT to apex), and outer layer of nonenhancing normal myocardium [56,79]. LGE was associated with poor functional class and higher chance of surgery [56]. In Churg Strauss syndrome, LGE is seen in apical and mid segments and in anterior and anteroseptal segments in a subendocardial distribution. In myocardial oxalosis, concentric LV thickening and diastolic dysfunction are seen. In Friedreich ataxia, concentric or asymmetric LV thickening, diastolic dysfunction, and fibrosis may be seen. Mucopolysaccharidoses have variable expression, including asymmetric septal thickening, mitral or aortic valve pathologies, and normal EF [52]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of restrictive cardiomyopathy. Ischemia has already been excluded. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of restrictive cardiomyopathy. Ischemia has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echo for the evaluation of restrictive cardiomyopathy. Echocardiography Transthoracic Resting Echocardiography is often the initial imaging test that identifies possible restrictive cardiomyopathy. Echocardiography can evaluate diastolic function with high accuracy, which is often impaired in early stages of several restrictive cardiomyopathies. | 3082580 |
acrac_3082580_14 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Decreased systolic and diastolic mitral annular velocities, restrictive pattern in mitral valve such as high velocity (E wave), short deceleration time and low late diastolic filling (A wave), and elevated filling pressures (E/e ratio) are seen [12,80]. Before the widespread use of harmonic imaging, the myocardium was described as having a characteristic speckled (starry sky) appearance [64], a finding now considered obsolete with the widespread use of harmonic imaging techniques. A relative apical sparing of longitudinal strain of 1.0 (average apical longitudinal strain/average of basal and mid longitudinal strain) has a high sensitivity (93%) and specificity (82%) in distinguishing cardiac amyloidosis from controls [81]. Apical thickening may be seen in endomyocardial fibrosis. In sarcoidosis, echocardiography shows ventricular septal thickening and diastolic dysfunction in the acute phase but thinning in the chronic phase with associated RWMA, aneurysm, and global systolic dysfunction [55]. Echocardiography Transthoracic Stress There is no relevant literature to support the use of echocardiography transthoracic stress for the evaluation of restrictive cardiomyopathy. Ischemia has already been excluded. Variant 3: Suspected nonischemic dilated and unclassified cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. DCM is characterized by a dilated ventricle and global systolic dysfunction. Ischemia is the most common cause of DCM and is excluded as discussed above. Approximately 50% of nonischemic DCM is idiopathic and is usually seen in a younger age group [2]. Other etiologies include toxins, familial inheritance, infections, infiltrative disorders, autoimmune conditions, metabolic derangements, and arrhythmias. Alcoholic cardiomyopathy is seen in heavy drinkers with probable genetic susceptibility, more common in men 30 to 55 years of age [2,82]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Decreased systolic and diastolic mitral annular velocities, restrictive pattern in mitral valve such as high velocity (E wave), short deceleration time and low late diastolic filling (A wave), and elevated filling pressures (E/e ratio) are seen [12,80]. Before the widespread use of harmonic imaging, the myocardium was described as having a characteristic speckled (starry sky) appearance [64], a finding now considered obsolete with the widespread use of harmonic imaging techniques. A relative apical sparing of longitudinal strain of 1.0 (average apical longitudinal strain/average of basal and mid longitudinal strain) has a high sensitivity (93%) and specificity (82%) in distinguishing cardiac amyloidosis from controls [81]. Apical thickening may be seen in endomyocardial fibrosis. In sarcoidosis, echocardiography shows ventricular septal thickening and diastolic dysfunction in the acute phase but thinning in the chronic phase with associated RWMA, aneurysm, and global systolic dysfunction [55]. Echocardiography Transthoracic Stress There is no relevant literature to support the use of echocardiography transthoracic stress for the evaluation of restrictive cardiomyopathy. Ischemia has already been excluded. Variant 3: Suspected nonischemic dilated and unclassified cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. DCM is characterized by a dilated ventricle and global systolic dysfunction. Ischemia is the most common cause of DCM and is excluded as discussed above. Approximately 50% of nonischemic DCM is idiopathic and is usually seen in a younger age group [2]. Other etiologies include toxins, familial inheritance, infections, infiltrative disorders, autoimmune conditions, metabolic derangements, and arrhythmias. Alcoholic cardiomyopathy is seen in heavy drinkers with probable genetic susceptibility, more common in men 30 to 55 years of age [2,82]. | 3082580 |
acrac_3082580_15 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Chemotherapeutic agents such as anthracyclines, tyrosine kinase inhibitors, trastuzumab, and interferons induce cardiomyopathy. There is a higher risk for cardiomyopathy with higher cumulative dose of chemotherapy, combination with other chemotherapeutic agents, associated radiation, and higher age. Acute cardiac changes can be seen as early as in a few hours after initiation, whereas late changes may be seen over decades with LV dilation and EF decrease, which limits the aggressive use of chemotherapy [83]. Peripartum cardiomyopathy is an idiopathic cardiomyopathy seen either in the late stage of pregnancy or in the first 5 months after delivery [84]. It is seen in 1 in 2,500 to 4,000 births in the United States [84]. Risk factors for peripartum cardiomyopathy include age >30 years, nonwhite background, multiparity, poor socioeconomic status, Nonischemic Myocardial Disease prolonged tocolytic therapy, hypertension, preeclampsia, and cocaine use [85]. These patients are evaluated with ECG, serological biomarkers, and imaging tests. Endomyocardial biopsy may be needed to exclude myocarditis. Several types of inherited muscular dystrophies can also produce DCM. These muscular dystrophies present with HF, arrhythmia, or sudden death by thromboembolism. There are several unclassified NICMs. LV noncompaction is characterized by prominent trabeculations due to persistent embryonic sinusoids, leading to LV failure, thromboembolism, and arrhythmias [86]. Stress-induced cardiomyopathy (also known as Takotsubo cardiomyopathy) is characterized by transient LV systolic dysfunction attributed to catecholamine release, possibly following a stressful event. It presents similarly to acute myocardial infarction with chest pain, ST-segment elevation on ECG, and elevated cardiac enzymes. It accounts for 2% of myocardial infarction with nonobstructive coronary arteries (MINOCA) [87]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Chemotherapeutic agents such as anthracyclines, tyrosine kinase inhibitors, trastuzumab, and interferons induce cardiomyopathy. There is a higher risk for cardiomyopathy with higher cumulative dose of chemotherapy, combination with other chemotherapeutic agents, associated radiation, and higher age. Acute cardiac changes can be seen as early as in a few hours after initiation, whereas late changes may be seen over decades with LV dilation and EF decrease, which limits the aggressive use of chemotherapy [83]. Peripartum cardiomyopathy is an idiopathic cardiomyopathy seen either in the late stage of pregnancy or in the first 5 months after delivery [84]. It is seen in 1 in 2,500 to 4,000 births in the United States [84]. Risk factors for peripartum cardiomyopathy include age >30 years, nonwhite background, multiparity, poor socioeconomic status, Nonischemic Myocardial Disease prolonged tocolytic therapy, hypertension, preeclampsia, and cocaine use [85]. These patients are evaluated with ECG, serological biomarkers, and imaging tests. Endomyocardial biopsy may be needed to exclude myocarditis. Several types of inherited muscular dystrophies can also produce DCM. These muscular dystrophies present with HF, arrhythmia, or sudden death by thromboembolism. There are several unclassified NICMs. LV noncompaction is characterized by prominent trabeculations due to persistent embryonic sinusoids, leading to LV failure, thromboembolism, and arrhythmias [86]. Stress-induced cardiomyopathy (also known as Takotsubo cardiomyopathy) is characterized by transient LV systolic dysfunction attributed to catecholamine release, possibly following a stressful event. It presents similarly to acute myocardial infarction with chest pain, ST-segment elevation on ECG, and elevated cardiac enzymes. It accounts for 2% of myocardial infarction with nonobstructive coronary arteries (MINOCA) [87]. | 3082580 |
acrac_3082580_16 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | One study found that incidental CAD was found in 10% of patients with stress-induced cardiomyopathy [88]. Diagnosis is made based on the Mayo Clinic or InterTAK diagnostic criteria [89]. LVOT obstruction, arrhythmia, shock, ventricular rupture, thrombus, and death may also be seen [2]. Cardiomyopathy can be seen in cirrhotic patients, independent of alcohol exposure. Patients with DCM are evaluated with history, clinical examination, lab tests, ECG, coronary angiography, and imaging. Arteriography Coronary There is no literature to support the use of coronary arteriography for the evaluation of nonischemic dilated or unclassified cardiomyopathy when ischemia has already been excluded. Stress-induced cardiomyopathy has been reported to be triggered by acute myocardial ischemia [90]. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography with ventriculography for the evaluation of nonischemic dilated or unclassified cardiomyopathy when ischemia has already been excluded. If performed, RWMA not explained by a culprit lesion may be seen in left ventriculography [90]. With LV apical ballooning patterns and normal coronaries on CTA or coronary angiography, stress-induced cardiomyopathy can be confirmed, except in patients with red flags for acute myocarditis, in which MRI is indicated. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of nonischemic dilated or unclassified cardiomyopathy. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of nonischemic DCM or unclassified cardiomyopathy. CT Heart Function and Morphology CT can be used for morphological and functional evaluation in patients in whom echocardiogram is suboptimal. CT is accurate in distinguishing idiopathic from ischemic DCM [91]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . One study found that incidental CAD was found in 10% of patients with stress-induced cardiomyopathy [88]. Diagnosis is made based on the Mayo Clinic or InterTAK diagnostic criteria [89]. LVOT obstruction, arrhythmia, shock, ventricular rupture, thrombus, and death may also be seen [2]. Cardiomyopathy can be seen in cirrhotic patients, independent of alcohol exposure. Patients with DCM are evaluated with history, clinical examination, lab tests, ECG, coronary angiography, and imaging. Arteriography Coronary There is no literature to support the use of coronary arteriography for the evaluation of nonischemic dilated or unclassified cardiomyopathy when ischemia has already been excluded. Stress-induced cardiomyopathy has been reported to be triggered by acute myocardial ischemia [90]. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography with ventriculography for the evaluation of nonischemic dilated or unclassified cardiomyopathy when ischemia has already been excluded. If performed, RWMA not explained by a culprit lesion may be seen in left ventriculography [90]. With LV apical ballooning patterns and normal coronaries on CTA or coronary angiography, stress-induced cardiomyopathy can be confirmed, except in patients with red flags for acute myocarditis, in which MRI is indicated. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of nonischemic dilated or unclassified cardiomyopathy. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of nonischemic DCM or unclassified cardiomyopathy. CT Heart Function and Morphology CT can be used for morphological and functional evaluation in patients in whom echocardiogram is suboptimal. CT is accurate in distinguishing idiopathic from ischemic DCM [91]. | 3082580 |
acrac_3082580_17 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | CT has been shown to be accurate in the diagnosis and characterization of LV noncompaction using the standard MRI criteria of end-diastolic noncompacted LV myocardial thickness to compacted LV myocardial thickness ratio of >2.3 [92]. CT can show the abnormalities of stress-induced cardiomyopathy, including absence of delayed enhancement [93,94]. CTA Coronary There is no relevant literature to support the use of CTA coronary for the evaluation of nonischemic DCM or unclassified cardiomyopathy when ischemic cardiomyopathy has already been excluded. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT as the first-line imaging modality in the evaluation of nonischemic or unclassified cardiomyopathy. One study found that nearly 50% of patients with unexplained cardiomyopathy and arrhythmia demonstrate focal inflammation in FDG-PET/CT, which is indicative of inflammatory cardiomyopathy [96]. Nonischemic Myocardial Disease MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of nonischemic DCM or unclassified cardiomyopathy. MRI Heart Function and Morphology In DCM, MRI helps in establishing the etiology and quantifying the abnormalities. Dilated ventricles, secondary tricuspid and/or mitral regurgitation due to annular dilation, regional ventricular dysfunction, ventricular wall thinning, and eccentric remodeling are seen. Myocardial infarct is diagnosed if there is subendocardial or transmural pattern of LGE in a vascular distribution. In idiopathic DCM with nonobstructed coronary arteries, linear or patchy mid myocardial LGE, primarily at the base and mid septum, is seen in 28% of patients. No LGE is seen in 59%. Subendocardial LGE is seen in 13% of these patients that is either due to atypical nonischemic fibrosis or silent ischemia from coronary embolus or recanalized plaque rupture [97]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . CT has been shown to be accurate in the diagnosis and characterization of LV noncompaction using the standard MRI criteria of end-diastolic noncompacted LV myocardial thickness to compacted LV myocardial thickness ratio of >2.3 [92]. CT can show the abnormalities of stress-induced cardiomyopathy, including absence of delayed enhancement [93,94]. CTA Coronary There is no relevant literature to support the use of CTA coronary for the evaluation of nonischemic DCM or unclassified cardiomyopathy when ischemic cardiomyopathy has already been excluded. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT as the first-line imaging modality in the evaluation of nonischemic or unclassified cardiomyopathy. One study found that nearly 50% of patients with unexplained cardiomyopathy and arrhythmia demonstrate focal inflammation in FDG-PET/CT, which is indicative of inflammatory cardiomyopathy [96]. Nonischemic Myocardial Disease MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of nonischemic DCM or unclassified cardiomyopathy. MRI Heart Function and Morphology In DCM, MRI helps in establishing the etiology and quantifying the abnormalities. Dilated ventricles, secondary tricuspid and/or mitral regurgitation due to annular dilation, regional ventricular dysfunction, ventricular wall thinning, and eccentric remodeling are seen. Myocardial infarct is diagnosed if there is subendocardial or transmural pattern of LGE in a vascular distribution. In idiopathic DCM with nonobstructed coronary arteries, linear or patchy mid myocardial LGE, primarily at the base and mid septum, is seen in 28% of patients. No LGE is seen in 59%. Subendocardial LGE is seen in 13% of these patients that is either due to atypical nonischemic fibrosis or silent ischemia from coronary embolus or recanalized plaque rupture [97]. | 3082580 |
acrac_3082580_18 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Using LGE, 19% of additional patients gained an indication for ICD, and 11% avoided a previously planned ICD compared with standard of care [98]. High T1 and ECV values show more sensitivity than LGE [68]. Native T1 value, ECV value, presence and extent of LGE, and EF correlate with adverse prognosis [99]. In chemotherapy cardiomyopathy, MRI helps in arbitrating discrepancies between imaging modalities, which may affect management. A reduction of EF by >10% or a reduction of EF >5% in symptomatic individuals is diagnostic of this entity (as long as the resultant EF is <53%) [83,100]. Early markers of cardiac involvement include elevated LV end-systolic volume (seen within 1 month); increased LV mass (due to edema); RWMA (decreased mid wall circumferential strain); high T1, T2, and ECV values; high signal in T2-weighted images (edema); and EGE [83]. Patients with edema are more likely to have right ventricular ejection fraction (RVEF) reduction at follow-up [100]. LGE can be seen in 0% to 100% of patients, either in mid myocardial or subepicardial distribution and rarely diffuse, indicating irreversible damage [101]. In late-onset cardiomyopathy in cancer survivors, abnormal or subnormal LVEF and RVEF, as well as high LV volumes without LGE, were seen at a median of 7.8 years after anthracycline therapy [102]. Increased ECV has been shown in cancer survivors [100]. LGE has been shown in 9% to 18% in mid myocardial, subepicardial, or RV insertion point distributions [101]. In peripartum cardiomyopathy, MRI provides additional information pertaining to diagnosis and prognosis, which are not obtained in echocardiography. Gadolinium contrast is avoided until after delivery. LV dilation, global LV systolic dysfunction, RV dysfunction, and LGE are seen [84]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Using LGE, 19% of additional patients gained an indication for ICD, and 11% avoided a previously planned ICD compared with standard of care [98]. High T1 and ECV values show more sensitivity than LGE [68]. Native T1 value, ECV value, presence and extent of LGE, and EF correlate with adverse prognosis [99]. In chemotherapy cardiomyopathy, MRI helps in arbitrating discrepancies between imaging modalities, which may affect management. A reduction of EF by >10% or a reduction of EF >5% in symptomatic individuals is diagnostic of this entity (as long as the resultant EF is <53%) [83,100]. Early markers of cardiac involvement include elevated LV end-systolic volume (seen within 1 month); increased LV mass (due to edema); RWMA (decreased mid wall circumferential strain); high T1, T2, and ECV values; high signal in T2-weighted images (edema); and EGE [83]. Patients with edema are more likely to have right ventricular ejection fraction (RVEF) reduction at follow-up [100]. LGE can be seen in 0% to 100% of patients, either in mid myocardial or subepicardial distribution and rarely diffuse, indicating irreversible damage [101]. In late-onset cardiomyopathy in cancer survivors, abnormal or subnormal LVEF and RVEF, as well as high LV volumes without LGE, were seen at a median of 7.8 years after anthracycline therapy [102]. Increased ECV has been shown in cancer survivors [100]. LGE has been shown in 9% to 18% in mid myocardial, subepicardial, or RV insertion point distributions [101]. In peripartum cardiomyopathy, MRI provides additional information pertaining to diagnosis and prognosis, which are not obtained in echocardiography. Gadolinium contrast is avoided until after delivery. LV dilation, global LV systolic dysfunction, RV dysfunction, and LGE are seen [84]. | 3082580 |
acrac_3082580_19 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | LGE is seen in 40% in a subepicardial or mid myocardial distribution in the anterior and anterolateral LV segments (occasionally subendocardial or transmural), more commonly in scans taken >7 days after the acute phase [84]. High T1 and T2 values and EGE are also seen in the acute stages [103]. Patients with LGE showed higher decompensation and did not regain LVEF [84]. Muscular dystrophies may present with ventricular dilation, and mid myocardial/subepicardial pattern of LGE, with occasional noncompacted myocardium. LGE may be present when echocardiography is still normal [104] and is an adverse prognostic determinant [84]. A higher amount of LGE is associated with lower LVEF, but LGE has a variable association with arrhythmia [104]. With longer duration of steroid treatment, lower increase in fibrosis burden was seen over time [105]. T1 and ECV values are also abnormal, which were associated with arrhythmia. Strain imaging shows abnormalities in earlier stages, before onset of overt HF, shows better serial decline in LV function, and provides reliable monitoring of progression of dystrophy [106]. LGE is also seen in mutation carriers [104]. Nonischemic Myocardial Disease used MRI diagnostic criteria for noncompaction, indicating that these criteria have poor specificity. This may, therefore, represent a variant anatomical phenotype than cardiomyopathy [112,113]. MRI in stress-induced cardiomyopathy shows reversible global systolic dysfunction and LV apical ballooning with normal or hyperkinetic basal segments and akinetic/hypokinetic apical segments. There are also reverse and mid ventricular variants. RV is involved in 40% of cases, which is associated with a worse prognosis [114]. Myocardial edema may be present, leading to a high signal in T2-weighted images, high native T1, and high T2 values, typically confined to the abnormal segment [115]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . LGE is seen in 40% in a subepicardial or mid myocardial distribution in the anterior and anterolateral LV segments (occasionally subendocardial or transmural), more commonly in scans taken >7 days after the acute phase [84]. High T1 and T2 values and EGE are also seen in the acute stages [103]. Patients with LGE showed higher decompensation and did not regain LVEF [84]. Muscular dystrophies may present with ventricular dilation, and mid myocardial/subepicardial pattern of LGE, with occasional noncompacted myocardium. LGE may be present when echocardiography is still normal [104] and is an adverse prognostic determinant [84]. A higher amount of LGE is associated with lower LVEF, but LGE has a variable association with arrhythmia [104]. With longer duration of steroid treatment, lower increase in fibrosis burden was seen over time [105]. T1 and ECV values are also abnormal, which were associated with arrhythmia. Strain imaging shows abnormalities in earlier stages, before onset of overt HF, shows better serial decline in LV function, and provides reliable monitoring of progression of dystrophy [106]. LGE is also seen in mutation carriers [104]. Nonischemic Myocardial Disease used MRI diagnostic criteria for noncompaction, indicating that these criteria have poor specificity. This may, therefore, represent a variant anatomical phenotype than cardiomyopathy [112,113]. MRI in stress-induced cardiomyopathy shows reversible global systolic dysfunction and LV apical ballooning with normal or hyperkinetic basal segments and akinetic/hypokinetic apical segments. There are also reverse and mid ventricular variants. RV is involved in 40% of cases, which is associated with a worse prognosis [114]. Myocardial edema may be present, leading to a high signal in T2-weighted images, high native T1, and high T2 values, typically confined to the abnormal segment [115]. | 3082580 |
acrac_3082580_20 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Edema diffuses more than myocardial ischemia and decreases within a few weeks unlike myocardial ischemia, which may take up to 3 months to diminish [115]. Typically, there is no LGE. However, recent studies have shown that LGE may be present in up to 40% of patients, typically in the areas of RWMA. This is usually of lower signal intensity (<5 SD above remote normal myocardium) than the LGE of myocardial infarction [87]. These patients may have irreversible damage with worse prognosis and longer recovery time [116,117]. MR diagnosis of stress-induced cardiomyopathy is made based on a typical pattern of LV dysfunction in a noncoronary pattern, myocardial edema corresponding to areas with RWMA, absence or insignificant LGE (<5 SD above remote normal myocardium), and markers for myocardial inflammation (EGE ratio > 4.0) [114]. MRI is superior to echocardiography in evaluating the RV involvement and complications [114]. Functional improvement occurs usually in 3 to 4 months but may take up to 12 months in 5% of patients; it may recur in 5% to 11% of patients [87]. Although stress-induced cardiomyopathy was typically thought to be completely reversible, recent literature indicates long-term clinical consequences [118]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of nonischemic DCM or unclassified cardiomyopathy when ischemia has already been excluded. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI vasodilator stress for the evaluation of nonischemic DCM or unclassified cardiomyopathy when ischemia has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography for the evaluation of nonischemic DCM or unclassified cardiomyopathy. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Edema diffuses more than myocardial ischemia and decreases within a few weeks unlike myocardial ischemia, which may take up to 3 months to diminish [115]. Typically, there is no LGE. However, recent studies have shown that LGE may be present in up to 40% of patients, typically in the areas of RWMA. This is usually of lower signal intensity (<5 SD above remote normal myocardium) than the LGE of myocardial infarction [87]. These patients may have irreversible damage with worse prognosis and longer recovery time [116,117]. MR diagnosis of stress-induced cardiomyopathy is made based on a typical pattern of LV dysfunction in a noncoronary pattern, myocardial edema corresponding to areas with RWMA, absence or insignificant LGE (<5 SD above remote normal myocardium), and markers for myocardial inflammation (EGE ratio > 4.0) [114]. MRI is superior to echocardiography in evaluating the RV involvement and complications [114]. Functional improvement occurs usually in 3 to 4 months but may take up to 12 months in 5% of patients; it may recur in 5% to 11% of patients [87]. Although stress-induced cardiomyopathy was typically thought to be completely reversible, recent literature indicates long-term clinical consequences [118]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of nonischemic DCM or unclassified cardiomyopathy when ischemia has already been excluded. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI vasodilator stress for the evaluation of nonischemic DCM or unclassified cardiomyopathy when ischemia has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography for the evaluation of nonischemic DCM or unclassified cardiomyopathy. | 3082580 |
acrac_3082580_21 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Echocardiography Transthoracic Resting Echocardiography can evaluate the function in several types of nonischemic DCM. It does not provide tissue characterization to identify the specific cause of cardiomyopathy, but the presence of systolic dysfunction in patients on chemotherapy, postpartum, and alcoholic patients is suggestive of cardiomyopathy. In chemotherapy, a reduction of EF by >10% or a reduction of EF >5% in symptomatic individuals is diagnostic of this entity (as long as the resultant EF is <53%). Calculation of LVEF by 3-D echocardiography is more reproducible and accurate than by 2-D echocardiography and is preferred for the evaluation and longitudinal assessment of patients treated with chemotherapy [100]. A 10% to 15% reduction of peak systolic global longitudinal strain by speckle-tracking echocardiography is the most useful parameter to predict cardiotoxicity [119]. Global radial and circumferential strains are abnormal in late survivors, but their clinical value is less proven [119]. Decreased global longitudinal strain with preserved EF is the most common echocardiographic abnormality in cancer survivors [100]. Echocardiography can confirm, quantify, and detect associated abnormalities and complications, as well as risk stratify patients [120]. In LV noncompaction, echocardiography shows a 2-layered structure with prominent LV trabeculations (end- systolic ratio >2) and deep perfused intertrabecular recesses in color Doppler [86,121]. The sensitivity and reproducibility of echocardiography is improved by using LV contrast [122]. LV strain is decreased in noncompacted as well as compacted segments [122]. Transient reversible global systolic dysfunction as well as RWMA (apical, mid ventricular, basal, or focal in anterolateral segment) are seen in stress-induced cardiomyopathy [95]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Echocardiography Transthoracic Resting Echocardiography can evaluate the function in several types of nonischemic DCM. It does not provide tissue characterization to identify the specific cause of cardiomyopathy, but the presence of systolic dysfunction in patients on chemotherapy, postpartum, and alcoholic patients is suggestive of cardiomyopathy. In chemotherapy, a reduction of EF by >10% or a reduction of EF >5% in symptomatic individuals is diagnostic of this entity (as long as the resultant EF is <53%). Calculation of LVEF by 3-D echocardiography is more reproducible and accurate than by 2-D echocardiography and is preferred for the evaluation and longitudinal assessment of patients treated with chemotherapy [100]. A 10% to 15% reduction of peak systolic global longitudinal strain by speckle-tracking echocardiography is the most useful parameter to predict cardiotoxicity [119]. Global radial and circumferential strains are abnormal in late survivors, but their clinical value is less proven [119]. Decreased global longitudinal strain with preserved EF is the most common echocardiographic abnormality in cancer survivors [100]. Echocardiography can confirm, quantify, and detect associated abnormalities and complications, as well as risk stratify patients [120]. In LV noncompaction, echocardiography shows a 2-layered structure with prominent LV trabeculations (end- systolic ratio >2) and deep perfused intertrabecular recesses in color Doppler [86,121]. The sensitivity and reproducibility of echocardiography is improved by using LV contrast [122]. LV strain is decreased in noncompacted as well as compacted segments [122]. Transient reversible global systolic dysfunction as well as RWMA (apical, mid ventricular, basal, or focal in anterolateral segment) are seen in stress-induced cardiomyopathy [95]. | 3082580 |
acrac_3082580_22 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Wall motion abnormalities show circular pattern in speckle echocardiography with improved detection using IV contrast [95]. Echocardiography Transthoracic Stress There is no relevant literature to support the use of echocardiography transthoracic stress for the evaluation of nonischemic DCM or idiopathic cardiomyopathy when ischemia has already been excluded. Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of arrhythmogenic cardiomyopathies. Arteriography Coronary with Ventriculography Imaging is initially performed with noninvasive tests such as MRI or CT. However, the 2010 criteria specifies RV angiographic criteria for ARVD, including regional RV akinesia, RV dyskinesia, or RV aneurysm [123]. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of arrhythmogenic cardiomyopathies. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of arrhythmogenic cardiomyopathies. CT Heart Function and Morphology ECG-gated cardiac CT shows wall motion abnormalities and allows quantification of ventricular volumes and function. RV myocardial fat may be seen but is nonspecific. A single study showed that a CT-based scoring system based on fatty tissue, bulging appearance, and dilation of RV had 87% sensitivity, 94.4% specificity, positive predictive value of 87%, negative predictive value of 94.4%, and accuracy of 92.2% for diagnosis of definitive ARVD [127]. CTA Coronary There is no relevant literature to support the use of coronary CTA for the evaluation of arrhythmogenic cardiomyopathies. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT for the evaluation of arrhythmogenic cardiomyopathies. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of arrhythmogenic cardiomyopathies. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Wall motion abnormalities show circular pattern in speckle echocardiography with improved detection using IV contrast [95]. Echocardiography Transthoracic Stress There is no relevant literature to support the use of echocardiography transthoracic stress for the evaluation of nonischemic DCM or idiopathic cardiomyopathy when ischemia has already been excluded. Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of arrhythmogenic cardiomyopathies. Arteriography Coronary with Ventriculography Imaging is initially performed with noninvasive tests such as MRI or CT. However, the 2010 criteria specifies RV angiographic criteria for ARVD, including regional RV akinesia, RV dyskinesia, or RV aneurysm [123]. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of arrhythmogenic cardiomyopathies. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of arrhythmogenic cardiomyopathies. CT Heart Function and Morphology ECG-gated cardiac CT shows wall motion abnormalities and allows quantification of ventricular volumes and function. RV myocardial fat may be seen but is nonspecific. A single study showed that a CT-based scoring system based on fatty tissue, bulging appearance, and dilation of RV had 87% sensitivity, 94.4% specificity, positive predictive value of 87%, negative predictive value of 94.4%, and accuracy of 92.2% for diagnosis of definitive ARVD [127]. CTA Coronary There is no relevant literature to support the use of coronary CTA for the evaluation of arrhythmogenic cardiomyopathies. FDG-PET/CT Heart There is no relevant literature to support the use of FDG-PET/CT for the evaluation of arrhythmogenic cardiomyopathies. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of arrhythmogenic cardiomyopathies. | 3082580 |
acrac_3082580_23 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic for the evaluation of arrhythmogenic cardiomyopathies. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of arrhythmogenic cardiomyopathies. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography for the evaluation of arrhythmogenic cardiomyopathies. Echocardiography Transthoracic Stress There is no relevant literature to support the use of echocardiographic transthoracic stress for the evaluation of arrhythmogenic cardiomyopathies. Variant 5: Suspected inflammatory cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. Inflammatory myocardial disease can present either in acute or subacute fashion. Acute myocarditis is due to infections (viral, bacterial, fungal, or tuberculosis), toxins, drugs, injuries, or idiopathic etiology. It can present with acute chest pain, elevated cardiac enzymes, and ECG changes that may mimic acute coronary syndrome (MINOCA). Other presentations include LV dysfunction, arrhythmias, and sudden cardiac death. Acute myocarditis accounts for up to 75% of patients who present with MINOCA, 12% of those with sudden death, and 9% of DCM [132]. Patients may recover or progress to DCM. Sarcoidosis may occasionally present in an acute fashion similar to acute myocarditis. Myocarditis can also be seen in rheumatological diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis [133]. Chagas diseases are caused by a parasite, Trypanosoma cruzi, which is endemic in Central and South America, with 13% of the population at risk and 11% affected [134]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic for the evaluation of arrhythmogenic cardiomyopathies. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of arrhythmogenic cardiomyopathies. Echocardiography Transesophageal There is no relevant literature to support the use of transesophageal echocardiography for the evaluation of arrhythmogenic cardiomyopathies. Echocardiography Transthoracic Stress There is no relevant literature to support the use of echocardiographic transthoracic stress for the evaluation of arrhythmogenic cardiomyopathies. Variant 5: Suspected inflammatory cardiomyopathy. Ischemic cardiomyopathy already excluded. Initial imaging. Inflammatory myocardial disease can present either in acute or subacute fashion. Acute myocarditis is due to infections (viral, bacterial, fungal, or tuberculosis), toxins, drugs, injuries, or idiopathic etiology. It can present with acute chest pain, elevated cardiac enzymes, and ECG changes that may mimic acute coronary syndrome (MINOCA). Other presentations include LV dysfunction, arrhythmias, and sudden cardiac death. Acute myocarditis accounts for up to 75% of patients who present with MINOCA, 12% of those with sudden death, and 9% of DCM [132]. Patients may recover or progress to DCM. Sarcoidosis may occasionally present in an acute fashion similar to acute myocarditis. Myocarditis can also be seen in rheumatological diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and systemic sclerosis [133]. Chagas diseases are caused by a parasite, Trypanosoma cruzi, which is endemic in Central and South America, with 13% of the population at risk and 11% affected [134]. | 3082580 |
acrac_3082580_24 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Chagas disease has an acute, a long indeterminate, and a chronic cardiac phase, with one-third of seropositive individuals developing chronic heart disease [135]. Cardiac Chagas presents as HF, arrhythmia, heart block, sudden death, and thromboembolic events [2]. Human immunodeficiency virus can cause cardiomyopathy in 8% of asymptomatic individuals [2]. There is no single test that can accurately diagnose inflammatory cardiomyopathy are evaluated using history, clinical examination, serology, ECG, and noninvasive imaging tests. Nonischemic Myocardial Disease Endomyocardial biopsy with histopathology, immunohistology, and molecular techniques may be necessary for diagnosis. Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of inflammatory myocardial disorders when ischemia has already been excluded. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography for the evaluation of inflammatory myocardial disorders. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of inflammatory myocardial disorders. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of inflammatory myocardial disorders. CT Heart Function and Morphology CT has been shown to display focal or multifocal enhancement and absence of coronary stenosis correlating with MRI [136]. CTA Coronary There is no relevant literature to support the use of CTA coronary arteries for the evaluation of inflammatory myocardial disorders. FDG-PET/CT Heart FDG-PET/CT may be useful in the evaluation of inflammatory cardiomyopathies, particularly in the evaluation of acute presentation of cardiac sarcoidosis [54,60]. FDG-PET/CT is not commonly used in the diagnosis of myocarditis. However, if performed, high uptake may be seen in FDG-PET/CT. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Chagas disease has an acute, a long indeterminate, and a chronic cardiac phase, with one-third of seropositive individuals developing chronic heart disease [135]. Cardiac Chagas presents as HF, arrhythmia, heart block, sudden death, and thromboembolic events [2]. Human immunodeficiency virus can cause cardiomyopathy in 8% of asymptomatic individuals [2]. There is no single test that can accurately diagnose inflammatory cardiomyopathy are evaluated using history, clinical examination, serology, ECG, and noninvasive imaging tests. Nonischemic Myocardial Disease Endomyocardial biopsy with histopathology, immunohistology, and molecular techniques may be necessary for diagnosis. Arteriography Coronary There is no relevant literature to support the use of coronary arteriography for the evaluation of inflammatory myocardial disorders when ischemia has already been excluded. Arteriography Coronary with Ventriculography There is no relevant literature to support the use of coronary arteriography for the evaluation of inflammatory myocardial disorders. CT Chest There is no relevant literature to support the use of CT chest for the evaluation of inflammatory myocardial disorders. CT Coronary Calcium There is no relevant literature to support the use of CT coronary calcium for the evaluation of inflammatory myocardial disorders. CT Heart Function and Morphology CT has been shown to display focal or multifocal enhancement and absence of coronary stenosis correlating with MRI [136]. CTA Coronary There is no relevant literature to support the use of CTA coronary arteries for the evaluation of inflammatory myocardial disorders. FDG-PET/CT Heart FDG-PET/CT may be useful in the evaluation of inflammatory cardiomyopathies, particularly in the evaluation of acute presentation of cardiac sarcoidosis [54,60]. FDG-PET/CT is not commonly used in the diagnosis of myocarditis. However, if performed, high uptake may be seen in FDG-PET/CT. | 3082580 |
acrac_3082580_25 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | In 111-antimyosin antibody can be used to identify myocarditis [14]. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of inflammatory myocardial disorders. MRI Heart Function and Morphology In acute myocarditis, MRI is performed in patients with symptoms of myocarditis, evidence of myocardial injury, and suspected viral etiology. MRI has been shown to have an impact on making a decision in >50% of patients and provides a new diagnosis in 11% of patients [115]. One study showed that using MRI at a lower threshold in patients with MINOCA (ie, using MRI independent of clinical likelihood of myocarditis) led to a 6.3-fold increase in the incidence of myocarditis with doubling of MRIs positive for myocarditis, indicating that myocarditis is currently an underdiagnosed entity [137]. MRI shows functional abnormalities (global systolic dysfunction or focal wall motion abnormalities), capillary hyperemia (high signal in EGE), edema (high signal in T2-weighted images, high native T1 and T2 values, increased ECV), necrosis/fibrosis (LGE in mid myocardial/subepicardial; high T1 and ECV), and pericardial effusion. The Lake Louise criteria, which were used in the diagnosis of acute myocarditis, required two out of the three criteria (edema, EGE, and/or LGE) to be positive [138]. A combination of all three is required if high positive predictive value is desired (positive likelihood ratio of 7.7, accuracy of 80%, specificity of 90%, sensitivity of 77%, positive predictive value of 96%, and negative predictive value of 53%), whereas T2 or LGE criteria are adequate for high sensitivity (91% sensitivity, 84% accuracy) [138]. Removing EGE as a criterion does not change the accuracy (80% with, 84% without) but reduces sensitivity (90% with, 60% without) [138]. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . In 111-antimyosin antibody can be used to identify myocarditis [14]. MRI Chest There is no relevant literature to support the use of MRI chest for the evaluation of inflammatory myocardial disorders. MRI Heart Function and Morphology In acute myocarditis, MRI is performed in patients with symptoms of myocarditis, evidence of myocardial injury, and suspected viral etiology. MRI has been shown to have an impact on making a decision in >50% of patients and provides a new diagnosis in 11% of patients [115]. One study showed that using MRI at a lower threshold in patients with MINOCA (ie, using MRI independent of clinical likelihood of myocarditis) led to a 6.3-fold increase in the incidence of myocarditis with doubling of MRIs positive for myocarditis, indicating that myocarditis is currently an underdiagnosed entity [137]. MRI shows functional abnormalities (global systolic dysfunction or focal wall motion abnormalities), capillary hyperemia (high signal in EGE), edema (high signal in T2-weighted images, high native T1 and T2 values, increased ECV), necrosis/fibrosis (LGE in mid myocardial/subepicardial; high T1 and ECV), and pericardial effusion. The Lake Louise criteria, which were used in the diagnosis of acute myocarditis, required two out of the three criteria (edema, EGE, and/or LGE) to be positive [138]. A combination of all three is required if high positive predictive value is desired (positive likelihood ratio of 7.7, accuracy of 80%, specificity of 90%, sensitivity of 77%, positive predictive value of 96%, and negative predictive value of 53%), whereas T2 or LGE criteria are adequate for high sensitivity (91% sensitivity, 84% accuracy) [138]. Removing EGE as a criterion does not change the accuracy (80% with, 84% without) but reduces sensitivity (90% with, 60% without) [138]. | 3082580 |
acrac_3082580_26 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | Native T1-mapping is useful in detecting subtle, focal disease with sensitivity of 90%, specificity of 91%, and accuracy of 91%, which is superior to T2-weighted MRI and LGE techniques [115]. The updated Lake Louise criteria requires at least one T2-based criterion (global/regional elevation of myocardial T2 or increased T2 signal of myocardium) with at least one T1-based criterion (elevated myocardial T1, elevated ECV, or LGE) for diagnosing acute myocarditis with high specificity [139]. Having only one criterion will still support a diagnosis of acute myocarditis but has lower specificity than with two criteria [139]. Different LGE patterns have been reported based on the viral etiology, with parvovirus B19 showing subepicardial or mid myocardial distribution LGE in the LV inferolateral wall and recovering Nonischemic Myocardial Disease without serious damage, whereas HHV-6 infection involves the LV basilar septum in linear mid myocardial LGE pattern, often rapidly progressing to HF [140]. Myocardial edema without fibrosis indicates good potential for recovery, whereas a high amount of EGE and LGE indicate adverse prognosis, particularly if LGE is persistent at 4 weeks after onset [2]. LGE may not correlate with the clinical and lab markers, indicating it is an independent risk assessment tool [141]. A normal MRI in patients with suspected myocarditis indicates a good long-term prognosis, independent of clinical and other findings [142]. In Chagas disease, patients are typically not imaged in the acute phase, but the indeterminate phase may show changes including RWMA and diastolic dysfunction without overt systolic dysfunction. The chronic phase shows global systolic dysfunction, apical aneurysm, and thrombus. LGE is seen in up to 72% of patients [135] and in 100% of those with arrhythmias, more common in apical and basal inferolateral segments. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . Native T1-mapping is useful in detecting subtle, focal disease with sensitivity of 90%, specificity of 91%, and accuracy of 91%, which is superior to T2-weighted MRI and LGE techniques [115]. The updated Lake Louise criteria requires at least one T2-based criterion (global/regional elevation of myocardial T2 or increased T2 signal of myocardium) with at least one T1-based criterion (elevated myocardial T1, elevated ECV, or LGE) for diagnosing acute myocarditis with high specificity [139]. Having only one criterion will still support a diagnosis of acute myocarditis but has lower specificity than with two criteria [139]. Different LGE patterns have been reported based on the viral etiology, with parvovirus B19 showing subepicardial or mid myocardial distribution LGE in the LV inferolateral wall and recovering Nonischemic Myocardial Disease without serious damage, whereas HHV-6 infection involves the LV basilar septum in linear mid myocardial LGE pattern, often rapidly progressing to HF [140]. Myocardial edema without fibrosis indicates good potential for recovery, whereas a high amount of EGE and LGE indicate adverse prognosis, particularly if LGE is persistent at 4 weeks after onset [2]. LGE may not correlate with the clinical and lab markers, indicating it is an independent risk assessment tool [141]. A normal MRI in patients with suspected myocarditis indicates a good long-term prognosis, independent of clinical and other findings [142]. In Chagas disease, patients are typically not imaged in the acute phase, but the indeterminate phase may show changes including RWMA and diastolic dysfunction without overt systolic dysfunction. The chronic phase shows global systolic dysfunction, apical aneurysm, and thrombus. LGE is seen in up to 72% of patients [135] and in 100% of those with arrhythmias, more common in apical and basal inferolateral segments. | 3082580 |
acrac_3082580_27 | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded | LGE has been reported in all the phases, including early indeterminate [135]. LGE is subendocardial in 27%, transmural in 36%, mid myocardial in 14%, and subepicardial in 23% of patients [143]. Hence, the pattern is not specific, with contributions possibly from myocarditis and microvascular dysfunction. The diagnosis is therefore made in the context of appropriate epidemiological history [143]. EGE and myocardial edema similar to that of acute myocarditis can also be seen in all phases [135]. All these parameters correlated directly with disease severity [143]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of inflammatory myocardial disorders. Ischemia has already been excluded. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of inflammatory myocardial disorders. Ischemia has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of echocardiography transesophageal for the evaluation of inflammatory myocardial disorders. Echocardiography Transthoracic Resting Echocardiography shows global and regional functional abnormalities in acute myocarditis. Pericardial effusion may also be seen. Echocardiography is a first-line imaging modality in the evaluation of Chagas disease. It may present with hypokinetic dilated LV with diminished LVEF or biventricular dilation. Aneurysms, thrombus, and valvular disease (mitral and tricuspid regurgitation) may be seen [144]. Global longitudinal strain correlates with the amount of myocardial fibrosis in MRI [145]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. | Nonischemic Myocardial Disease with Clinical Manifestations Ischemic Cardiomyopathy Already Excluded . LGE has been reported in all the phases, including early indeterminate [135]. LGE is subendocardial in 27%, transmural in 36%, mid myocardial in 14%, and subepicardial in 23% of patients [143]. Hence, the pattern is not specific, with contributions possibly from myocarditis and microvascular dysfunction. The diagnosis is therefore made in the context of appropriate epidemiological history [143]. EGE and myocardial edema similar to that of acute myocarditis can also be seen in all phases [135]. All these parameters correlated directly with disease severity [143]. MRI Heart Inotropic Stress There is no relevant literature to support the use of MRI heart inotropic stress for the evaluation of inflammatory myocardial disorders. Ischemia has already been excluded. MRI Heart Vasodilator Stress There is no relevant literature to support the use of MRI heart vasodilator stress for the evaluation of inflammatory myocardial disorders. Ischemia has already been excluded. Echocardiography Transesophageal There is no relevant literature to support the use of echocardiography transesophageal for the evaluation of inflammatory myocardial disorders. Echocardiography Transthoracic Resting Echocardiography shows global and regional functional abnormalities in acute myocarditis. Pericardial effusion may also be seen. Echocardiography is a first-line imaging modality in the evaluation of Chagas disease. It may present with hypokinetic dilated LV with diminished LVEF or biventricular dilation. Aneurysms, thrombus, and valvular disease (mitral and tricuspid regurgitation) may be seen [144]. Global longitudinal strain correlates with the amount of myocardial fibrosis in MRI [145]. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch. acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation. | 3082580 |
acrac_3101591_0 | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery | Introduction/Background Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy. Breast reconstruction options following mastectomy range from saline or silicone implants to autologous breast reconstruction. The latter procedure uses skin, fat, blood vessels, and/or muscle from the upper back, abdomen, buttocks, or hips. Transverse rectus abdominis muscle flap procedure is a traditional method of breast reconstruction that harvests underlying muscle. This can result in increased donor site morbidity. The deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle [1]. Compared with transversus rectus abdominus muscle flaps, DIEP flaps result in less fat necrosis and loss of function at the donor site. The DIEP tissue harvesting procedure involves dissecting the anterior abdominal wall subcutaneous tissues to locate and visually identify the most suitable vessel to serve as the vascular pedicle. Although the DIEA is reliably identified because of its consistent take off from the external iliac artery, the anatomy of the perforators used in DIEP flap is variable. Lack of preoperative imaging can lead to increased operative times given the time-consuming nature of identifying the variable vascular anatomy. The efficiency of the vascular pedicle selection process can be significantly improved with preoperative imaging [2]. Multiple perforators are identified by imaging, which are typically ranked based on size, location, and intramuscular course. The ideal perforator is the largest caliber [1,3] and is medially located within the flap with an extended vascular territory beyond the midline to provide optimal perfusion. | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Introduction/Background Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy. Breast reconstruction options following mastectomy range from saline or silicone implants to autologous breast reconstruction. The latter procedure uses skin, fat, blood vessels, and/or muscle from the upper back, abdomen, buttocks, or hips. Transverse rectus abdominis muscle flap procedure is a traditional method of breast reconstruction that harvests underlying muscle. This can result in increased donor site morbidity. The deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle [1]. Compared with transversus rectus abdominus muscle flaps, DIEP flaps result in less fat necrosis and loss of function at the donor site. The DIEP tissue harvesting procedure involves dissecting the anterior abdominal wall subcutaneous tissues to locate and visually identify the most suitable vessel to serve as the vascular pedicle. Although the DIEA is reliably identified because of its consistent take off from the external iliac artery, the anatomy of the perforators used in DIEP flap is variable. Lack of preoperative imaging can lead to increased operative times given the time-consuming nature of identifying the variable vascular anatomy. The efficiency of the vascular pedicle selection process can be significantly improved with preoperative imaging [2]. Multiple perforators are identified by imaging, which are typically ranked based on size, location, and intramuscular course. The ideal perforator is the largest caliber [1,3] and is medially located within the flap with an extended vascular territory beyond the midline to provide optimal perfusion. | 3101591 |
acrac_3101591_1 | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery | Dissection of the selected perforator should preserve muscle innervation and avoid fat necrosis [1,3,4]. A short intramuscular course allows for successful dissection [3,14,15]. Perforators are reported by the location where they pierce the anterior rectus sheath in relation to the umbilicus. This is important because, although the perforator can move within the subcutaneous tissues with applied pressure, its position at the rectus sheath is fixed relative to the umbilicus [5]. 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. 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] OR Discussion of Procedures by Variant Variant 1: Imaging of deep inferior epigastric arteries for surgical planning (breast reconstruction surgery). Initial imaging. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients, and even between the left and right hemiabdomen of the same patient. | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Dissection of the selected perforator should preserve muscle innervation and avoid fat necrosis [1,3,4]. A short intramuscular course allows for successful dissection [3,14,15]. Perforators are reported by the location where they pierce the anterior rectus sheath in relation to the umbilicus. This is important because, although the perforator can move within the subcutaneous tissues with applied pressure, its position at the rectus sheath is fixed relative to the umbilicus [5]. 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. 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] OR Discussion of Procedures by Variant Variant 1: Imaging of deep inferior epigastric arteries for surgical planning (breast reconstruction surgery). Initial imaging. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients, and even between the left and right hemiabdomen of the same patient. | 3101591 |
acrac_3101591_2 | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery | Improved clinical outcomes with preoperative imaging have been shown to include decreased length of surgery, decreased flap loss rate, decreased hernia rate, decreased intraoperative blood loss, shorter mean inpatient stay, reduced learning curve when compared with hand-held Doppler, and increased surgeon confidence [7-15]. Arteriography Abdomen and Pelvis Although catheter directed arteriography can aid in delineation of variant anatomy of the DIEA to guide surgical planning for breast reconstruction, it is an invasive procedure with risks that outweigh benefits compared to current alternative noninvasive imaging methods. Additionally, given the small caliber of the vessels and potentially tortuous course, this would likely lead to prolonged procedure times and potentially unreliable assessment of vessel caliber given variable source and detector distances. Furthermore, the course of perforator arteries in the abdominal wall musculature and subcutaneous tissues is not easily assessed with catheter directed arteriography. There is no relevant literature supporting the use of arteriography in evaluation of imaging of deep inferior epigastric arteries for surgical planning. CT Abdomen and Pelvis With IV Contrast To date, there is no relevant literature supporting the use of CT abdomen and pelvis with intravenous (IV) contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning. CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without and with IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning. CT Abdomen and Pelvis Without IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning. | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . Improved clinical outcomes with preoperative imaging have been shown to include decreased length of surgery, decreased flap loss rate, decreased hernia rate, decreased intraoperative blood loss, shorter mean inpatient stay, reduced learning curve when compared with hand-held Doppler, and increased surgeon confidence [7-15]. Arteriography Abdomen and Pelvis Although catheter directed arteriography can aid in delineation of variant anatomy of the DIEA to guide surgical planning for breast reconstruction, it is an invasive procedure with risks that outweigh benefits compared to current alternative noninvasive imaging methods. Additionally, given the small caliber of the vessels and potentially tortuous course, this would likely lead to prolonged procedure times and potentially unreliable assessment of vessel caliber given variable source and detector distances. Furthermore, the course of perforator arteries in the abdominal wall musculature and subcutaneous tissues is not easily assessed with catheter directed arteriography. There is no relevant literature supporting the use of arteriography in evaluation of imaging of deep inferior epigastric arteries for surgical planning. CT Abdomen and Pelvis With IV Contrast To date, there is no relevant literature supporting the use of CT abdomen and pelvis with intravenous (IV) contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning. CT Abdomen and Pelvis Without and With IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without and with IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning. CT Abdomen and Pelvis Without IV Contrast There is no relevant literature supporting the use of CT abdomen and pelvis without IV contrast in the evaluation of imaging of deep inferior epigastric arteries for surgical planning. | 3101591 |
acrac_3101591_3 | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery | CTA Abdomen and Pelvis With IV Contrast CTA is currently beneficial in evaluating the perforator anatomy for preoperative planning before DIEP flap breast reconstruction. Perforator size, perforator location relative to abdominal landmarks, branching pattern of DIEA, presence of superficial inferior epigastric vessels, subcutaneous course, and intramuscular course all affect operative techniques, operative time, and outcomes. CTA is a fast, efficient, and highly reproducible modality, capable of yielding excellent opacification of the small caliber perforator arteries with optimal contrast bolus timing. CTA evaluation performed with the use of specific postprocessing and display techniques may yield more accurate assessment of the optimal vessel for selection for breast reconstruction when compared to color Doppler ultrasound (CDU) [2,8,16]. Some studies have demonstrated superiority of CTA over CDU utilization [17,18], suggesting a routine use of preoperative CTA. A virtual 3-D plan based on CTA can be preoperatively projected onto the abdomen intraoperatively, which can aid in identifying perforator locations and thus decreasing operative time [19]. CTA is also helpful in predicting which DIEA perforators are the most clinically useful in patients with scarred abdomens [20]. Therefore, preoperative imaging is essential for DIEP flap surgery [17,21-28]. Preoperative CTA evaluation can also reliably estimate the volume of abdominal tissue for DIEP flap breast reconstruction [19,29]. Imaging of Deep Inferior Epigastric Arteries Preoperative mapping allows calculation of a flap viability index, which predicts the amount of tissue which will survive based on perforator diameter as well as flap weights [30]. CTA evaluation also allows for the assessment of factors, which may lead to venous congestion of the flap and, therefore, flap failure [31]. | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . CTA Abdomen and Pelvis With IV Contrast CTA is currently beneficial in evaluating the perforator anatomy for preoperative planning before DIEP flap breast reconstruction. Perforator size, perforator location relative to abdominal landmarks, branching pattern of DIEA, presence of superficial inferior epigastric vessels, subcutaneous course, and intramuscular course all affect operative techniques, operative time, and outcomes. CTA is a fast, efficient, and highly reproducible modality, capable of yielding excellent opacification of the small caliber perforator arteries with optimal contrast bolus timing. CTA evaluation performed with the use of specific postprocessing and display techniques may yield more accurate assessment of the optimal vessel for selection for breast reconstruction when compared to color Doppler ultrasound (CDU) [2,8,16]. Some studies have demonstrated superiority of CTA over CDU utilization [17,18], suggesting a routine use of preoperative CTA. A virtual 3-D plan based on CTA can be preoperatively projected onto the abdomen intraoperatively, which can aid in identifying perforator locations and thus decreasing operative time [19]. CTA is also helpful in predicting which DIEA perforators are the most clinically useful in patients with scarred abdomens [20]. Therefore, preoperative imaging is essential for DIEP flap surgery [17,21-28]. Preoperative CTA evaluation can also reliably estimate the volume of abdominal tissue for DIEP flap breast reconstruction [19,29]. Imaging of Deep Inferior Epigastric Arteries Preoperative mapping allows calculation of a flap viability index, which predicts the amount of tissue which will survive based on perforator diameter as well as flap weights [30]. CTA evaluation also allows for the assessment of factors, which may lead to venous congestion of the flap and, therefore, flap failure [31]. | 3101591 |
acrac_3101591_4 | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery | A superficial inferior epigastric vein larger than the deep inferior epigastric vein as well as axial nonarborizing superficial venous system are highly predictive of subsequent venous congestion. Knowledge of these findings can aid in preoperative discussion with patients, which may alter management [32]. Preoperative use of CTA allows estimation of contralateral abdominal perfusion and therefore allows for efficient breast reconstruction and decreased complications [33]. Use of preoperative CTA has been shown to result in the increased use of single perforators, increased use of medial- row perforators, significantly reduced operative time, decreased intraoperative blood loss, decreased inpatient hospital stay, and decreased complications such as hernias [9,11,12,14,34]. CTA evaluation allows for faster selection of laterality of dissection, as well as reduced flap loss rates [15]. MRA Abdomen and Pelvis Without and With IV Contrast Donor site preoperative imaging for mapping the perforator artery anatomy results in improvement in perforator selection, reduces operative time, and reduces donor site morbidity. Although CTA is considered most helpful, emerging literature supports MR angiography (MRA) as an alternative imaging tool with accurate assessment of DIEA perforator anatomy [35-44]. A recent meta-analysis demonstrates that CT and MRI appear to have similar accuracy in preoperative DIEP mapping [44]. MRA evaluation is limited by increased scanning times relative to CTA evaluation. Continued research is needed to evaluate the accuracy of the new emerging MRA techniques and their role in preoperative perforator branch imaging. MRA Abdomen and Pelvis Without IV Contrast The literature review yields one study that used noncontrast MRA for preoperative planning in 56 women who underwent DIEP flap with preoperative planning using MRA without IV contrast. | Imaging of Deep Inferior Epigastric Arteries for Surgical Planning Breast Reconstruction Surgery . A superficial inferior epigastric vein larger than the deep inferior epigastric vein as well as axial nonarborizing superficial venous system are highly predictive of subsequent venous congestion. Knowledge of these findings can aid in preoperative discussion with patients, which may alter management [32]. Preoperative use of CTA allows estimation of contralateral abdominal perfusion and therefore allows for efficient breast reconstruction and decreased complications [33]. Use of preoperative CTA has been shown to result in the increased use of single perforators, increased use of medial- row perforators, significantly reduced operative time, decreased intraoperative blood loss, decreased inpatient hospital stay, and decreased complications such as hernias [9,11,12,14,34]. CTA evaluation allows for faster selection of laterality of dissection, as well as reduced flap loss rates [15]. MRA Abdomen and Pelvis Without and With IV Contrast Donor site preoperative imaging for mapping the perforator artery anatomy results in improvement in perforator selection, reduces operative time, and reduces donor site morbidity. Although CTA is considered most helpful, emerging literature supports MR angiography (MRA) as an alternative imaging tool with accurate assessment of DIEA perforator anatomy [35-44]. A recent meta-analysis demonstrates that CT and MRI appear to have similar accuracy in preoperative DIEP mapping [44]. MRA evaluation is limited by increased scanning times relative to CTA evaluation. Continued research is needed to evaluate the accuracy of the new emerging MRA techniques and their role in preoperative perforator branch imaging. MRA Abdomen and Pelvis Without IV Contrast The literature review yields one study that used noncontrast MRA for preoperative planning in 56 women who underwent DIEP flap with preoperative planning using MRA without IV contrast. | 3101591 |
acrac_69488_0 | Hearing Loss and or Vertigo | Introduction/Background Clinical assessment and audiometric testing can determine the type of hearing loss as conductive, sensorineural, or mixed [1,2] and guide the appropriateness of subsequent imaging. Conductive hearing loss results from diseases affecting the conduction of mechanical sound wave energy to the hair cells of the organ of Corti within the cochlea. These serve as the auditory receptors, converting the mechanical energy of sound waves into electrical neural impulses that are then transmitted along the auditory pathways to the auditory cortex [1]. Sensorineural hearing loss is caused by diseases that impair the cochlear function or the transmission of electrical signal along the auditory pathway, including the cranial nerve nucleus in the brainstem through the superior olive, inferior colliculus, medial geniculate body of the thalamus, and auditory cortex in the temporal lobe. Given the proximity of the cranial nerves and their nuclei, disorders that affect hearing may also affect vestibular function and vice versa. The vestibule and semicircular canals are the end organs responsible for balance and equilibrium. Central vestibular pathways involve extensive connections between the vestibular nuclei within the brainstem and the cerebellum, extraocular nuclei, and spinal cord. Vertigo is a sensation that you or the environment around you is moving or spinning. Although vertigo often indicates dysfunction of the vestibule or semicircular canals, patients commonly report dizziness, a less specific term that may imply disequilibrium, light- headedness, or presyncope [3-5]. Accordingly, imaging workup in these patients may require assessment for disease processes that produce symptoms reported as dizziness rather than vertigo. | Hearing Loss and or Vertigo. Introduction/Background Clinical assessment and audiometric testing can determine the type of hearing loss as conductive, sensorineural, or mixed [1,2] and guide the appropriateness of subsequent imaging. Conductive hearing loss results from diseases affecting the conduction of mechanical sound wave energy to the hair cells of the organ of Corti within the cochlea. These serve as the auditory receptors, converting the mechanical energy of sound waves into electrical neural impulses that are then transmitted along the auditory pathways to the auditory cortex [1]. Sensorineural hearing loss is caused by diseases that impair the cochlear function or the transmission of electrical signal along the auditory pathway, including the cranial nerve nucleus in the brainstem through the superior olive, inferior colliculus, medial geniculate body of the thalamus, and auditory cortex in the temporal lobe. Given the proximity of the cranial nerves and their nuclei, disorders that affect hearing may also affect vestibular function and vice versa. The vestibule and semicircular canals are the end organs responsible for balance and equilibrium. Central vestibular pathways involve extensive connections between the vestibular nuclei within the brainstem and the cerebellum, extraocular nuclei, and spinal cord. Vertigo is a sensation that you or the environment around you is moving or spinning. Although vertigo often indicates dysfunction of the vestibule or semicircular canals, patients commonly report dizziness, a less specific term that may imply disequilibrium, light- headedness, or presyncope [3-5]. Accordingly, imaging workup in these patients may require assessment for disease processes that produce symptoms reported as dizziness rather than vertigo. | 69488 |
acrac_69488_1 | Hearing Loss and or Vertigo | Appropriateness of imaging often depends upon clinical categorization of vertigo into peripheral (vestibular) and central (affecting central vestibular pathways) categories based upon factors such as onset, duration, persistence, aggravating factors, and results of clinical testing [3-7]. In some cases however, this categorization may be difficult on clinical assessment, especially in less subspecialized care [3]. 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] Hearing Loss and/or Vertigo Given the density of temporal bone and the rather small size of individual structures of interest, such as ossicles, details of temporal bone morphology are only evident on bone windows. Accordingly, intravenous (IV) contrast is not beneficial for evaluation of temporal bone in patients with conductive hearing loss. CT Head There is no evidence to support use of CT head in patients with conductive hearing loss. CTA Head There is no evidence to support use of CT angiography (CTA) in patients with conductive hearing loss. MRI Head and Internal Auditory Canal MRI of the temporal bone is insufficient in delineation of the bony details usually needed for evaluation of patients with conductive hearing loss, and there is no evidence to support its use as a first-line imaging modality in these patients. MRA Head There is no evidence to support use of MR angiography (MRA) for initial evaluation of patients with conductive hearing loss. MR Venography Head There is no evidence to support use of MR venography (MRV) for initial evaluation of patients with conductive hearing loss. | Hearing Loss and or Vertigo. Appropriateness of imaging often depends upon clinical categorization of vertigo into peripheral (vestibular) and central (affecting central vestibular pathways) categories based upon factors such as onset, duration, persistence, aggravating factors, and results of clinical testing [3-7]. In some cases however, this categorization may be difficult on clinical assessment, especially in less subspecialized care [3]. 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] Hearing Loss and/or Vertigo Given the density of temporal bone and the rather small size of individual structures of interest, such as ossicles, details of temporal bone morphology are only evident on bone windows. Accordingly, intravenous (IV) contrast is not beneficial for evaluation of temporal bone in patients with conductive hearing loss. CT Head There is no evidence to support use of CT head in patients with conductive hearing loss. CTA Head There is no evidence to support use of CT angiography (CTA) in patients with conductive hearing loss. MRI Head and Internal Auditory Canal MRI of the temporal bone is insufficient in delineation of the bony details usually needed for evaluation of patients with conductive hearing loss, and there is no evidence to support its use as a first-line imaging modality in these patients. MRA Head There is no evidence to support use of MR angiography (MRA) for initial evaluation of patients with conductive hearing loss. MR Venography Head There is no evidence to support use of MR venography (MRV) for initial evaluation of patients with conductive hearing loss. | 69488 |
acrac_69488_2 | Hearing Loss and or Vertigo | Variant 2: Acquired conductive hearing loss secondary to cholesteatoma or neoplasm with suspected intracranial or inner ear extension. Surgical planning. CT Temporal Bone High-spatial resolution CT of the temporal bone is helpful in defining small inflammatory or neoplastic masses within the middle ear cavity [1,2,13]. In addition, CT can help in surgical planning by demonstrating erosions of ossicles or other inner ear structures (such as perilymphatic fistulae) caused by such masses [14]. Given the surrounding dense bone, IV contrast is usually not beneficial in studying enhancement characteristics of middle ear masses. However, contrast enhancement may help delineate extraosseous soft tissue associated with invasive neoplasms. CT Head There is no evidence to support use of CT head for assessment of patients with conductive hearing loss and middle ear mass identified on otoscopy. CTA Head There is no definite evidence to support use of CTA as a first-line modality for assessment of patients with conductive hearing loss and middle ear mass identified on otoscopy. However, in patients with high clinical suspicion of middle ear paraganglioma, CTA is sometimes used initially for diagnostic confirmation and for planning further management. MRI Head and Internal Auditory Canal Extent of a middle ear cavity mass identified on otoscopy in a patient with conductive hearing loss is much better defined using MRI obtained without and with IV contrast [2,5,13,15]. This assessment is better done using thin sections across the temporal bone as part of a dedicated internal auditory canal (IAC) protocol rather than a routine brain MRI. Excellent soft-tissue contrast afforded by even a noncontrast MRI often complements the bony details seen on temporal bone CT for complete evaluation of such patients prior to surgical intervention. MRA Head MRA is usually not used as a first-line imaging modality in patients presenting with conductive hearing loss. | Hearing Loss and or Vertigo. Variant 2: Acquired conductive hearing loss secondary to cholesteatoma or neoplasm with suspected intracranial or inner ear extension. Surgical planning. CT Temporal Bone High-spatial resolution CT of the temporal bone is helpful in defining small inflammatory or neoplastic masses within the middle ear cavity [1,2,13]. In addition, CT can help in surgical planning by demonstrating erosions of ossicles or other inner ear structures (such as perilymphatic fistulae) caused by such masses [14]. Given the surrounding dense bone, IV contrast is usually not beneficial in studying enhancement characteristics of middle ear masses. However, contrast enhancement may help delineate extraosseous soft tissue associated with invasive neoplasms. CT Head There is no evidence to support use of CT head for assessment of patients with conductive hearing loss and middle ear mass identified on otoscopy. CTA Head There is no definite evidence to support use of CTA as a first-line modality for assessment of patients with conductive hearing loss and middle ear mass identified on otoscopy. However, in patients with high clinical suspicion of middle ear paraganglioma, CTA is sometimes used initially for diagnostic confirmation and for planning further management. MRI Head and Internal Auditory Canal Extent of a middle ear cavity mass identified on otoscopy in a patient with conductive hearing loss is much better defined using MRI obtained without and with IV contrast [2,5,13,15]. This assessment is better done using thin sections across the temporal bone as part of a dedicated internal auditory canal (IAC) protocol rather than a routine brain MRI. Excellent soft-tissue contrast afforded by even a noncontrast MRI often complements the bony details seen on temporal bone CT for complete evaluation of such patients prior to surgical intervention. MRA Head MRA is usually not used as a first-line imaging modality in patients presenting with conductive hearing loss. | 69488 |
acrac_69488_3 | Hearing Loss and or Vertigo | However, it may be helpful in assessing patency of the carotid artery if initial imaging raises suspicion of vascular involvement. MR Venography Head Although not used as the initial imaging modality, MRV may be helpful in assessing patency of jugular vein for surgical planning in patients with documented middle ear masses. Hearing Loss and/or Vertigo Variant 3: Acquired sensorineural hearing loss. Initial imaging. CT Temporal Bone CT of the temporal bone is insensitive in detection of soft-tissue abnormalities that commonly cause sensorineural hearing loss. Small size and proximity to the dense bone of inner ear structures and IAC also precludes visualization of intralabyrinthine or intracanalicular enhancement following IV contrast administration. It may demonstrate labyrinthine ossification [16] resulting from prior infection or give an indirect clue to presence of a vestibular schwannoma in the form of bony remodeling of the IAC. In post-traumatic sensorineural hearing loss, CT can demonstrate fractures extending across the otic capsule [2,13]. CT Head Contrast-enhanced head CT is a less-sensitive imaging modality to detect tumors, such as vestibular schwannomas [17], or assess the IAC, cerebellopontine angle cisterns, or the brainstem compared to MRI. CTA Head There is no evidence to support use of CTA in the initial workup of patients presenting with isolated sensorineural hearing loss. MRI Head and Internal Auditory Canal Imaging evaluation of patients presenting with sensorineural hearing loss involves detailed assessment of the cochlear contents, vestibulocochlear nerve, and auditory pathways. MRI is the imaging modality of choice for evaluating these soft-tissue structures [2,5,18-20]. | Hearing Loss and or Vertigo. However, it may be helpful in assessing patency of the carotid artery if initial imaging raises suspicion of vascular involvement. MR Venography Head Although not used as the initial imaging modality, MRV may be helpful in assessing patency of jugular vein for surgical planning in patients with documented middle ear masses. Hearing Loss and/or Vertigo Variant 3: Acquired sensorineural hearing loss. Initial imaging. CT Temporal Bone CT of the temporal bone is insensitive in detection of soft-tissue abnormalities that commonly cause sensorineural hearing loss. Small size and proximity to the dense bone of inner ear structures and IAC also precludes visualization of intralabyrinthine or intracanalicular enhancement following IV contrast administration. It may demonstrate labyrinthine ossification [16] resulting from prior infection or give an indirect clue to presence of a vestibular schwannoma in the form of bony remodeling of the IAC. In post-traumatic sensorineural hearing loss, CT can demonstrate fractures extending across the otic capsule [2,13]. CT Head Contrast-enhanced head CT is a less-sensitive imaging modality to detect tumors, such as vestibular schwannomas [17], or assess the IAC, cerebellopontine angle cisterns, or the brainstem compared to MRI. CTA Head There is no evidence to support use of CTA in the initial workup of patients presenting with isolated sensorineural hearing loss. MRI Head and Internal Auditory Canal Imaging evaluation of patients presenting with sensorineural hearing loss involves detailed assessment of the cochlear contents, vestibulocochlear nerve, and auditory pathways. MRI is the imaging modality of choice for evaluating these soft-tissue structures [2,5,18-20]. | 69488 |
acrac_69488_4 | Hearing Loss and or Vertigo | MRI can demonstrate signal alterations induced by inflammation or hemorrhage within the cochlear contents, identify neoplasms within the cochlear labyrinth or IAC, assess the size of vestibular aqueducts, and visualize abnormalities affecting the brain parenchyma along the auditory pathways [21-25]. Although differential considerations may vary based upon sudden, fluctuating, or progressive nature of sensorineural hearing loss, MRI remains the imaging modality of choice for all these subcategories. MRI should be done using dedicated IAC protocol using thin sections across the IAC and the inner ear. These protocols include evaluation of the brainstem and thalami. Given the extreme rarity of cortical deafness, there is no strong evidence to recommend routine assessment of the entire brain parenchyma in addition to the MRI IAC protocol in patients presenting with isolated sensorineural hearing loss [26,27]. High-resolution 3-D T2-weighted images providing submillimeter assessment of fluid-filled inner ear structures and the IAC are highly sensitive for detection of diseases presenting with sensorineural hearing loss [27,28]. Visualization of inflammatory changes (eg, labyrinthitis, neuritis) as well as neoplasms, such as vestibular schwannomas, can be facilitated by administration of IV contrast [29,30]. However, there is insufficient evidence to prove incremental benefit of contrast administration beyond an MRI IAC protocol performed without IV contrast [27,28]. MRA Head There is no evidence to support use of MRA in the initial workup of patients presenting with isolated sensorineural hearing loss. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with isolated sensorineural hearing loss. Variant 4: Mixed conductive and sensorineural hearing loss. Initial imaging. CT Temporal Bone CT scan of the temporal bones can delineate changes of otospongiosis, a common cause of mixed conductive and sensorineural hearing loss. | Hearing Loss and or Vertigo. MRI can demonstrate signal alterations induced by inflammation or hemorrhage within the cochlear contents, identify neoplasms within the cochlear labyrinth or IAC, assess the size of vestibular aqueducts, and visualize abnormalities affecting the brain parenchyma along the auditory pathways [21-25]. Although differential considerations may vary based upon sudden, fluctuating, or progressive nature of sensorineural hearing loss, MRI remains the imaging modality of choice for all these subcategories. MRI should be done using dedicated IAC protocol using thin sections across the IAC and the inner ear. These protocols include evaluation of the brainstem and thalami. Given the extreme rarity of cortical deafness, there is no strong evidence to recommend routine assessment of the entire brain parenchyma in addition to the MRI IAC protocol in patients presenting with isolated sensorineural hearing loss [26,27]. High-resolution 3-D T2-weighted images providing submillimeter assessment of fluid-filled inner ear structures and the IAC are highly sensitive for detection of diseases presenting with sensorineural hearing loss [27,28]. Visualization of inflammatory changes (eg, labyrinthitis, neuritis) as well as neoplasms, such as vestibular schwannomas, can be facilitated by administration of IV contrast [29,30]. However, there is insufficient evidence to prove incremental benefit of contrast administration beyond an MRI IAC protocol performed without IV contrast [27,28]. MRA Head There is no evidence to support use of MRA in the initial workup of patients presenting with isolated sensorineural hearing loss. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with isolated sensorineural hearing loss. Variant 4: Mixed conductive and sensorineural hearing loss. Initial imaging. CT Temporal Bone CT scan of the temporal bones can delineate changes of otospongiosis, a common cause of mixed conductive and sensorineural hearing loss. | 69488 |
acrac_69488_5 | Hearing Loss and or Vertigo | In some patients with clinical suspicion of otospongiosis, it may suggest alternate diagnoses to explain hearing loss. [31,32]. Administration of IV contrast is usually not beneficial for assessment of temporal bone. CT Head Relative to MRI, CT head is much less sensitive in detecting or excluding retrocochlear pathology to account for the sensorineural component of the hearing loss [17]. CTA Head There is no evidence to support use of CTA in the initial workup of patients presenting with mixed hearing loss. Hearing Loss and/or Vertigo MRI Head and Internal Auditory Canal MRI obtained using IAC protocol can be helpful in looking for any retrocochlear pathology responsible for a sensorineural component of the hearing loss. In case IV contrast is administered, punctate enhancement can be seen within the bony otic capsule in the presence of otospongiosis [2]. MRA Head There is no evidence to support use of MRA in the initial workup of patients presenting with mixed hearing loss. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with mixed hearing loss. Variant 5: Congenital hearing loss or total deafness or cochlear implant candidate. Surgical planning. CT Temporal Bone High-spatial resolution provided by CT of the temporal bone is valuable prior to cochlear implantation surgery in patients with profound hearing loss. It can provide preoperative delineation of underlying cochlear malformation in patients with congenital hearing loss, detect changes of otospongiosis, suggest round window occlusion, identify labyrinthitis ossificans, congenital bony fusion of the ossicles, and alert the surgeon regarding underlying otomastoiditis or variant anatomy (such as that of the facial nerve) [33,34]. It can also delineate the size of cochlear and vestibular aqueducts, alerting the surgeon for possibility of intraoperative cerebrospinal fluid gusher [24,35,36]. | Hearing Loss and or Vertigo. In some patients with clinical suspicion of otospongiosis, it may suggest alternate diagnoses to explain hearing loss. [31,32]. Administration of IV contrast is usually not beneficial for assessment of temporal bone. CT Head Relative to MRI, CT head is much less sensitive in detecting or excluding retrocochlear pathology to account for the sensorineural component of the hearing loss [17]. CTA Head There is no evidence to support use of CTA in the initial workup of patients presenting with mixed hearing loss. Hearing Loss and/or Vertigo MRI Head and Internal Auditory Canal MRI obtained using IAC protocol can be helpful in looking for any retrocochlear pathology responsible for a sensorineural component of the hearing loss. In case IV contrast is administered, punctate enhancement can be seen within the bony otic capsule in the presence of otospongiosis [2]. MRA Head There is no evidence to support use of MRA in the initial workup of patients presenting with mixed hearing loss. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with mixed hearing loss. Variant 5: Congenital hearing loss or total deafness or cochlear implant candidate. Surgical planning. CT Temporal Bone High-spatial resolution provided by CT of the temporal bone is valuable prior to cochlear implantation surgery in patients with profound hearing loss. It can provide preoperative delineation of underlying cochlear malformation in patients with congenital hearing loss, detect changes of otospongiosis, suggest round window occlusion, identify labyrinthitis ossificans, congenital bony fusion of the ossicles, and alert the surgeon regarding underlying otomastoiditis or variant anatomy (such as that of the facial nerve) [33,34]. It can also delineate the size of cochlear and vestibular aqueducts, alerting the surgeon for possibility of intraoperative cerebrospinal fluid gusher [24,35,36]. | 69488 |
acrac_69488_6 | Hearing Loss and or Vertigo | CT Head High-spatial resolution of CT head is insufficient in providing anatomic details of temporal bone needed for surgical planning prior to cochlear implantation. Accordingly, there is no evidence to support routine use of CT head for this indication. CTA Head There is no evidence to support routine use of CTA for surgical planning prior to cochlear implantation in patients with deafness. MRI Head and Internal Auditory Canal MRI may provide a complementary role to temporal bone CT in preoperative assessment of patients prior to cochlear implantation. Exquisite details of inner ear structures visible on high-resolution T2-weighted images can help in detecting abnormalities, such as cochlear malformations or cochlear nerve deficiency, that directly impact surgical approach [37,38]. In addition, MRI may reveal unexpected soft-tissue abnormalities, such as vestibular schwannomas that may impact the planned surgery [39]. MRA Head There is no evidence to support routine use of MRA for surgical planning prior to cochlear implantation in patients with deafness. MR Venography Head There is no evidence to support routine use of MRV for surgical planning prior to cochlear implantation in patients with deafness. Variant 6: Episodic vertigo with or without associated hearing loss or aural fullness (peripheral vertigo). Initial imaging. CT Temporal Bone CT of the temporal bone provides excellent delineation of the bony labyrinth and is helpful in detecting a number of pathologies resulting in peripheral vertigo. It is highly sensitive in detecting temporal bone fractures in patients with post-traumatic vertigo, assessing for superior semicircular canal dehiscence in patients with vertigo provoked by loud noises, and diagnosing erosions in the bony labyrinth from inflammatory or iatrogenic causes [5,8,9,14]. CT Head CT head provides insufficient details of the inner ear to be useful in patients with peripheral vertigo. | Hearing Loss and or Vertigo. CT Head High-spatial resolution of CT head is insufficient in providing anatomic details of temporal bone needed for surgical planning prior to cochlear implantation. Accordingly, there is no evidence to support routine use of CT head for this indication. CTA Head There is no evidence to support routine use of CTA for surgical planning prior to cochlear implantation in patients with deafness. MRI Head and Internal Auditory Canal MRI may provide a complementary role to temporal bone CT in preoperative assessment of patients prior to cochlear implantation. Exquisite details of inner ear structures visible on high-resolution T2-weighted images can help in detecting abnormalities, such as cochlear malformations or cochlear nerve deficiency, that directly impact surgical approach [37,38]. In addition, MRI may reveal unexpected soft-tissue abnormalities, such as vestibular schwannomas that may impact the planned surgery [39]. MRA Head There is no evidence to support routine use of MRA for surgical planning prior to cochlear implantation in patients with deafness. MR Venography Head There is no evidence to support routine use of MRV for surgical planning prior to cochlear implantation in patients with deafness. Variant 6: Episodic vertigo with or without associated hearing loss or aural fullness (peripheral vertigo). Initial imaging. CT Temporal Bone CT of the temporal bone provides excellent delineation of the bony labyrinth and is helpful in detecting a number of pathologies resulting in peripheral vertigo. It is highly sensitive in detecting temporal bone fractures in patients with post-traumatic vertigo, assessing for superior semicircular canal dehiscence in patients with vertigo provoked by loud noises, and diagnosing erosions in the bony labyrinth from inflammatory or iatrogenic causes [5,8,9,14]. CT Head CT head provides insufficient details of the inner ear to be useful in patients with peripheral vertigo. | 69488 |
acrac_69488_7 | Hearing Loss and or Vertigo | Accordingly, diagnostic yield of CT head in patients presenting with vertigo is low [40]. Hearing Loss and/or Vertigo CTA Head and Neck There is no evidence to support use of CTA in patients presenting with peripheral causes of vertigo. In patients with episodic vertigo that cannot be confidently categorized as peripheral, CTA can be used to detect underlying vertebrobasilar insufficiency [41]. MRI Head and Internal Auditory Canal Based on clinical assessment, peripheral vertigo in many patients is presumed to be secondary to benign processes such as benign paroxysmal positional vertigo or Meniere disease, and these patients are often managed successfully without images are capable of delineating endolymphatic sac, and delayed 3-D FLAIR images can demonstrate hydrops associated with Meniere disease following IV or intratympanic contrast administration as contrast accumulates in perilymphatic but not endolymphatic space. However, the role of such studies in management of these patients is still not clearly established [42-53]. IV contrast can be helpful in showing enhancement of vestibule or semicircular canals in patients with labyrinthitis. MRI of the brain can be used to detect rare but significant central causes of vertigo in cases where distinction between peripheral and central categories is not clinically evident [54]. MRA Head and Neck There is no evidence to support use of MRA in patients presenting with peripheral causes of vertigo. In patients with episodic vertigo that cannot be confidently categorized as peripheral, MRA without and with IV contrast can be used to detect underlying vertebrobasilar insufficiency [55]. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with vertigo; however, in patients who may have vertigo as a symptom of pseudotumor cerebri, MRV may show narrowing of the transverse sinuses. Variant 7: Persistent vertigo with or without neurological symptoms (central vertigo). Initial imaging. | Hearing Loss and or Vertigo. Accordingly, diagnostic yield of CT head in patients presenting with vertigo is low [40]. Hearing Loss and/or Vertigo CTA Head and Neck There is no evidence to support use of CTA in patients presenting with peripheral causes of vertigo. In patients with episodic vertigo that cannot be confidently categorized as peripheral, CTA can be used to detect underlying vertebrobasilar insufficiency [41]. MRI Head and Internal Auditory Canal Based on clinical assessment, peripheral vertigo in many patients is presumed to be secondary to benign processes such as benign paroxysmal positional vertigo or Meniere disease, and these patients are often managed successfully without images are capable of delineating endolymphatic sac, and delayed 3-D FLAIR images can demonstrate hydrops associated with Meniere disease following IV or intratympanic contrast administration as contrast accumulates in perilymphatic but not endolymphatic space. However, the role of such studies in management of these patients is still not clearly established [42-53]. IV contrast can be helpful in showing enhancement of vestibule or semicircular canals in patients with labyrinthitis. MRI of the brain can be used to detect rare but significant central causes of vertigo in cases where distinction between peripheral and central categories is not clinically evident [54]. MRA Head and Neck There is no evidence to support use of MRA in patients presenting with peripheral causes of vertigo. In patients with episodic vertigo that cannot be confidently categorized as peripheral, MRA without and with IV contrast can be used to detect underlying vertebrobasilar insufficiency [55]. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with vertigo; however, in patients who may have vertigo as a symptom of pseudotumor cerebri, MRV may show narrowing of the transverse sinuses. Variant 7: Persistent vertigo with or without neurological symptoms (central vertigo). Initial imaging. | 69488 |
acrac_69488_8 | Hearing Loss and or Vertigo | CT Temporal Bone CT of the temporal bone is not useful in looking for central causes of vertigo. CT Head Head CT without or with IV contrast may be used to look for central causes of dizziness, albeit with lesser sensitivity than MRI [40,54]. IV contrast may help in either detection or characterization of various neoplastic or inflammatory disease processes affecting the central nervous system. In patients presenting to the emergency department with acute onset of symptoms, CT may demonstrate intracranial hemorrhage as a rare central cause of dizziness [56]. CTA Head and Neck In patients suspected of vertebrobasilar insufficiency as a cause of episodic vertigo, CTA can be used to detect vascular stenosis or occlusion [41]. MRI Head and Internal Auditory Canal MRI is the modality of choice in evaluation of the brain in patients suspected to have central cause for vertigo. It can detect posterior fossa neoplasms, Chiari malformation, posterior fossa infarcts, and demyelinating lesions that may result in dizziness or vertigo [3,54,56-58]. Contrast administration can be helpful in detection or characterization of such lesions [58]. Compared to CT, MRI has a much higher sensitivity of detecting acute infarcts in patients with dizziness [40]. It should be noted that infarcts causing isolated vestibular symptoms are usually small, and normal initial MRI does not entirely exclude brain infarction as a cause for vertigo [59]. MRA Head and Neck In patients suspected of vertebrobasilar insufficiency as a cause of episodic vertigo, MRA can be used to detect vascular stenosis or occlusion [55]. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with isolated vertigo. Summary of Recommendations Variant 1: CT temporal bone without IV contrast is the first-line imaging modality in patients presenting with acquired conductive hearing loss without any mass lesion seen within the middle ear cavity. | Hearing Loss and or Vertigo. CT Temporal Bone CT of the temporal bone is not useful in looking for central causes of vertigo. CT Head Head CT without or with IV contrast may be used to look for central causes of dizziness, albeit with lesser sensitivity than MRI [40,54]. IV contrast may help in either detection or characterization of various neoplastic or inflammatory disease processes affecting the central nervous system. In patients presenting to the emergency department with acute onset of symptoms, CT may demonstrate intracranial hemorrhage as a rare central cause of dizziness [56]. CTA Head and Neck In patients suspected of vertebrobasilar insufficiency as a cause of episodic vertigo, CTA can be used to detect vascular stenosis or occlusion [41]. MRI Head and Internal Auditory Canal MRI is the modality of choice in evaluation of the brain in patients suspected to have central cause for vertigo. It can detect posterior fossa neoplasms, Chiari malformation, posterior fossa infarcts, and demyelinating lesions that may result in dizziness or vertigo [3,54,56-58]. Contrast administration can be helpful in detection or characterization of such lesions [58]. Compared to CT, MRI has a much higher sensitivity of detecting acute infarcts in patients with dizziness [40]. It should be noted that infarcts causing isolated vestibular symptoms are usually small, and normal initial MRI does not entirely exclude brain infarction as a cause for vertigo [59]. MRA Head and Neck In patients suspected of vertebrobasilar insufficiency as a cause of episodic vertigo, MRA can be used to detect vascular stenosis or occlusion [55]. MR Venography Head There is no evidence to support use of MRV in the initial workup of patients presenting with isolated vertigo. Summary of Recommendations Variant 1: CT temporal bone without IV contrast is the first-line imaging modality in patients presenting with acquired conductive hearing loss without any mass lesion seen within the middle ear cavity. | 69488 |
Subsets and Splits