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_69473_6 | Palpable Abdominal Mass Suspected Neoplasm | In a systematic review of the literature on abdominal wall endometriosis, the authors concluded that the overall quality of evidence is poor with no prospective studies; however, US or MRI can assist with localization and aid in surgical planning [39]. US has several limitations. It can be less specific than other imaging modalities for characterizing masses [31]. US visibility of the abdominal wall is usually possible with few limitations. However, US may not provide details of deeper structures and relationship of masses to anatomic fascial planes. US also has advantages; it has the benefit of real-time imaging, such as assessing dynamic changes like Valsalva maneuvers, when evaluating for hernias. US is considered highly useful for real-time guidance for biopsy, but percutaneous biopsy should be considered carefully and in conjunction with oncologic specialist when a sarcoma is suspected [30]. MRI Abdomen There is little recent literature on the diagnostic accuracy of MRI for abdominal wall mass evaluation. MRI acquired without and with IV contrast is recognized as a useful modality to further narrow the differential diagnosis of detected masses, because of its high soft-tissue contrast resolution, ability to differentiate fat and enhancement within structures, and sequences that identify iron and blood products that may aid in differential considerations, such as endometriosis or extramedullary hematopoiesis [10,35]. MRI acquired without and with IV contrast can depict specific imaging features for many entities, including endometriosis, simple lipomas, epidermoid cysts, desmoid tumors, and hematomas [38]. MRI acquired without IV contrast may also still depict soft-tissue structures and define anatomy/pathology. MRI may be a useful second-line examination, often recommended if a malignant or indeterminate mass is detected on US [29,30]. In a series of 126 consecutive cases | Palpable Abdominal Mass Suspected Neoplasm. In a systematic review of the literature on abdominal wall endometriosis, the authors concluded that the overall quality of evidence is poor with no prospective studies; however, US or MRI can assist with localization and aid in surgical planning [39]. US has several limitations. It can be less specific than other imaging modalities for characterizing masses [31]. US visibility of the abdominal wall is usually possible with few limitations. However, US may not provide details of deeper structures and relationship of masses to anatomic fascial planes. US also has advantages; it has the benefit of real-time imaging, such as assessing dynamic changes like Valsalva maneuvers, when evaluating for hernias. US is considered highly useful for real-time guidance for biopsy, but percutaneous biopsy should be considered carefully and in conjunction with oncologic specialist when a sarcoma is suspected [30]. MRI Abdomen There is little recent literature on the diagnostic accuracy of MRI for abdominal wall mass evaluation. MRI acquired without and with IV contrast is recognized as a useful modality to further narrow the differential diagnosis of detected masses, because of its high soft-tissue contrast resolution, ability to differentiate fat and enhancement within structures, and sequences that identify iron and blood products that may aid in differential considerations, such as endometriosis or extramedullary hematopoiesis [10,35]. MRI acquired without and with IV contrast can depict specific imaging features for many entities, including endometriosis, simple lipomas, epidermoid cysts, desmoid tumors, and hematomas [38]. MRI acquired without IV contrast may also still depict soft-tissue structures and define anatomy/pathology. MRI may be a useful second-line examination, often recommended if a malignant or indeterminate mass is detected on US [29,30]. In a series of 126 consecutive cases | 69473 |
acrac_69473_7 | Palpable Abdominal Mass Suspected Neoplasm | Palpable Abdominal Mass-Suspected Neoplasm of fatty masses, MRI had a sensitivity of 100%, specificity of 83%, accuracy of 84%, and negative predictive value of 100% for differentiating simple lipoma from liposarcoma [40]. Although helpful in defining relationship of masses to adjacent fascia, muscles, and vessels, MRI is often not specific enough to establish a definitive diagnosis, and biopsy or excision is usually required following consultation or referral by oncologic specialists [29,38]. CT Abdomen There is little recent literature on the accuracy and diagnostic yield of CT for abdominal wall masses; however, CT is widely considered fast and accurate for excluding or confirming a mass. Because of the relative lack of soft- tissue resolution compared with MRI, it may not be a first- or second-line option for evaluation of abdominal masses. CT may be additionally helpful in the setting of suspected hernia, congenital abnormalities, hematomas, and infections [41,42]. Additionally, there may be a role in the setting of endometriosis for differentiation from other masses [43]. When malignant masses are suspected, CT may provide benefit of staging information related to metastatic disease in addition to defining the size, location, and relationship of a mass to adjacent structures. There are no recent studies that specifically address the question of whether CT should be performed with or without IV contrast for a palpable mass. Acquisition of CT both with and without contrast does not generally add diagnostic value. Although available evidence and experience generally supports the appropriateness of CT with IV contrast over that of noncontrast CT for evaluation of intra-abdominal organs and pathology [12,14,15], the use of noncontrast CT may be of value in some circumstances. CT may be of benefit in guiding biopsy and should be considered carefully and in conjunction with oncologic specialist when a sarcoma is suspected [30]. | Palpable Abdominal Mass Suspected Neoplasm. Palpable Abdominal Mass-Suspected Neoplasm of fatty masses, MRI had a sensitivity of 100%, specificity of 83%, accuracy of 84%, and negative predictive value of 100% for differentiating simple lipoma from liposarcoma [40]. Although helpful in defining relationship of masses to adjacent fascia, muscles, and vessels, MRI is often not specific enough to establish a definitive diagnosis, and biopsy or excision is usually required following consultation or referral by oncologic specialists [29,38]. CT Abdomen There is little recent literature on the accuracy and diagnostic yield of CT for abdominal wall masses; however, CT is widely considered fast and accurate for excluding or confirming a mass. Because of the relative lack of soft- tissue resolution compared with MRI, it may not be a first- or second-line option for evaluation of abdominal masses. CT may be additionally helpful in the setting of suspected hernia, congenital abnormalities, hematomas, and infections [41,42]. Additionally, there may be a role in the setting of endometriosis for differentiation from other masses [43]. When malignant masses are suspected, CT may provide benefit of staging information related to metastatic disease in addition to defining the size, location, and relationship of a mass to adjacent structures. There are no recent studies that specifically address the question of whether CT should be performed with or without IV contrast for a palpable mass. Acquisition of CT both with and without contrast does not generally add diagnostic value. Although available evidence and experience generally supports the appropriateness of CT with IV contrast over that of noncontrast CT for evaluation of intra-abdominal organs and pathology [12,14,15], the use of noncontrast CT may be of value in some circumstances. CT may be of benefit in guiding biopsy and should be considered carefully and in conjunction with oncologic specialist when a sarcoma is suspected [30]. | 69473 |
acrac_3102397_0 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | Twins As an independent marker of fetal aneuploidy, nuchal translucency is particularly useful in twins because of the inability of maternal serum markers or age to identify the fetus at risk. Nuchal translucency measurement allows each fetus of a twin pregnancy to be assessed individually; the distribution of measurements does not differ significantly between singletons and twins so that standard thresholds can be used [9,10]. In dichorionic twins, fetus-specific risks are calculated on the assumption each twin has an independent risk reflected by its own nuchal translucency [2,11,12]. In monochorionic twins, a pregnancy-specific risk is calculated using the average nuchal translucency thickness of both fetuses [2,13]. As in singletons, increased nuchal translucency may also be a marker of fetal structural anomalies, genetic syndromes, and intrauterine demise in twins. 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] Nuchal Translucency Evaluation Special Imaging Considerations Measurement of the nuchal translucency has been standardized in order to improve its performance in screening for fetal aneuploidy. Quality assurance programs for nuchal translucency assessment have been established by the Fetal Medicine Foundation in London and the Nuchal Translucency Quality Review in the United States. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. Twins As an independent marker of fetal aneuploidy, nuchal translucency is particularly useful in twins because of the inability of maternal serum markers or age to identify the fetus at risk. Nuchal translucency measurement allows each fetus of a twin pregnancy to be assessed individually; the distribution of measurements does not differ significantly between singletons and twins so that standard thresholds can be used [9,10]. In dichorionic twins, fetus-specific risks are calculated on the assumption each twin has an independent risk reflected by its own nuchal translucency [2,11,12]. In monochorionic twins, a pregnancy-specific risk is calculated using the average nuchal translucency thickness of both fetuses [2,13]. As in singletons, increased nuchal translucency may also be a marker of fetal structural anomalies, genetic syndromes, and intrauterine demise in twins. 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] Nuchal Translucency Evaluation Special Imaging Considerations Measurement of the nuchal translucency has been standardized in order to improve its performance in screening for fetal aneuploidy. Quality assurance programs for nuchal translucency assessment have been established by the Fetal Medicine Foundation in London and the Nuchal Translucency Quality Review in the United States. | 3102397 |
acrac_3102397_1 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | The ACR Appropriateness Criteria methodology assumes that each imaging procedures is performed and interpreted by an expert, but it should be noted that there remains considerable inter- and intra-observer variability in nuchal translucency measurements, highlighting the importance of ongoing quality assessment [14,15]. First trimester screening algorithms can be improved by assessing for the presence or absence of the nasal bone and adjusting aneuploidy risk calculations accordingly [16]. The absence of the nasal bone at 11 to 14 weeks is another powerful US marker of fetal aneuploidy; it improves the performance of early screening by decreasing the false- positive rate to 2.5% [16]. Other first trimester US markers of fetal aneuploidy such as increased frontomaxillary facial angle, an aberrant right subclavian artery, presence of tricuspid regurgitation, reversed a-wave in the ductus venosus, and increased iliac wing angle have not been incorporated into routine screening algorithms and their clinical usefulness in the general population remains uncertain [17]. The role of nuchal translucency measurement in the new era of cell-free fetal DNA screening is also uncertain. It is recommended that a first trimester US for the sole purpose of nuchal translucency screening not be performed in patients with negative cell-free fetal DNA [18]. OR Discussion of Procedures by Variant Variant 1: Routine nuchal translucency measurement at 11 to 14 weeks of gestation for single or twin gestations. Initial imaging. US Duplex Doppler Pregnant Uterus Although the utility of Doppler imaging has been investigated in research protocols, there is no literature to support a recommendation to universally incorporate Doppler studies into routine first trimester screening algorithms for fetal aneuploidy [17]. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. The ACR Appropriateness Criteria methodology assumes that each imaging procedures is performed and interpreted by an expert, but it should be noted that there remains considerable inter- and intra-observer variability in nuchal translucency measurements, highlighting the importance of ongoing quality assessment [14,15]. First trimester screening algorithms can be improved by assessing for the presence or absence of the nasal bone and adjusting aneuploidy risk calculations accordingly [16]. The absence of the nasal bone at 11 to 14 weeks is another powerful US marker of fetal aneuploidy; it improves the performance of early screening by decreasing the false- positive rate to 2.5% [16]. Other first trimester US markers of fetal aneuploidy such as increased frontomaxillary facial angle, an aberrant right subclavian artery, presence of tricuspid regurgitation, reversed a-wave in the ductus venosus, and increased iliac wing angle have not been incorporated into routine screening algorithms and their clinical usefulness in the general population remains uncertain [17]. The role of nuchal translucency measurement in the new era of cell-free fetal DNA screening is also uncertain. It is recommended that a first trimester US for the sole purpose of nuchal translucency screening not be performed in patients with negative cell-free fetal DNA [18]. OR Discussion of Procedures by Variant Variant 1: Routine nuchal translucency measurement at 11 to 14 weeks of gestation for single or twin gestations. Initial imaging. US Duplex Doppler Pregnant Uterus Although the utility of Doppler imaging has been investigated in research protocols, there is no literature to support a recommendation to universally incorporate Doppler studies into routine first trimester screening algorithms for fetal aneuploidy [17]. | 3102397 |
acrac_3102397_2 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | Given the theoretical risk of thermal damage to the developing fetus from the use of color and pulsed Doppler US, its use is not advised when the nuchal translucency is of normal thickness or below the threshold of 3 mm at 11 to 14 weeks of gestation [2,19]. US Echocardiography Fetal In the absence of other maternal or fetal risk factors, there is no literature to support the routine use of fetal echocardiography in patients with normal nuchal translucency measurements at 11 to 14 weeks of gestation [20]. US Pregnant Uterus Transabdominal ACOG recommends aneuploidy screening or diagnostic testing be offered to all women in early pregnancy [2]. For women who choose screening over invasive diagnostic testing, first trimester combined screening with nuchal translucency and maternal serum markers remains a reasonable option for single and twin gestations [2,18,21]. Although ACOG does not endorse a specific screening test, citing that no one screening test is superior to another in all test characteristics, there are several benefits of first trimester screening, including maternal privacy, early reassurance, and timely detection of fetal abnormalities with the option for earlier and safer pregnancy termination [2]. Using the nuchal translucency measurement and maternal serum pregnancy-associated plasma protein A and free beta subunit of human chorionic gonadotropin levels, most laboratories will report specific risk estimates for trisomy 21, 18, and 13 after adjusting for crown-rump length and maternal factors such as age, prior history of aneuploidy, weight, and race [2]. In clinical practice, first trimester combined screening for aneuploidy detects about 90% of affected pregnancies at a false positive rate of 5% for single gestations with slightly lower sensitivities reported for twins [12,17]. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. Given the theoretical risk of thermal damage to the developing fetus from the use of color and pulsed Doppler US, its use is not advised when the nuchal translucency is of normal thickness or below the threshold of 3 mm at 11 to 14 weeks of gestation [2,19]. US Echocardiography Fetal In the absence of other maternal or fetal risk factors, there is no literature to support the routine use of fetal echocardiography in patients with normal nuchal translucency measurements at 11 to 14 weeks of gestation [20]. US Pregnant Uterus Transabdominal ACOG recommends aneuploidy screening or diagnostic testing be offered to all women in early pregnancy [2]. For women who choose screening over invasive diagnostic testing, first trimester combined screening with nuchal translucency and maternal serum markers remains a reasonable option for single and twin gestations [2,18,21]. Although ACOG does not endorse a specific screening test, citing that no one screening test is superior to another in all test characteristics, there are several benefits of first trimester screening, including maternal privacy, early reassurance, and timely detection of fetal abnormalities with the option for earlier and safer pregnancy termination [2]. Using the nuchal translucency measurement and maternal serum pregnancy-associated plasma protein A and free beta subunit of human chorionic gonadotropin levels, most laboratories will report specific risk estimates for trisomy 21, 18, and 13 after adjusting for crown-rump length and maternal factors such as age, prior history of aneuploidy, weight, and race [2]. In clinical practice, first trimester combined screening for aneuploidy detects about 90% of affected pregnancies at a false positive rate of 5% for single gestations with slightly lower sensitivities reported for twins [12,17]. | 3102397 |
acrac_3102397_3 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | US Pregnant Uterus Transvaginal Transvaginal US may be utilized for first trimester aneuploidy screening if optimal views of the nuchal translucency cannot be obtained using the transabdominal approach, which occurs in about 5% of patients [5,24,28]. The higher resolution of transvaginal US can be particularly helpful when imaging women with high body mass indexes. The transvaginal approach may also be favored in patients with multiple abdominal surgeries or presenting with a transverse fetal lie in the lower aspect of the uterus. However, reduced probe mobility limits the available image planes, so using a combination of transabdominal and transvaginal US may be necessary to fully assess the first trimester fetus. Fetal nuchal translucency measurements are similar whether measured by transabdominal or transvaginal US as long as the same principles for image acquisition and nuchal translucency measurement are applied [29]. The transvaginal approach may produce better quality images to assess the nasal bone than transabdominal US [65]. However, perhaps because of the restricted range of movement, a 3-fold higher failure of nasal bone imaging has been reported with transvaginal US [30]. If there is difficulty obtaining the nuchal translucency measurement, there is likely to be difficulty in obtaining the proper image to assess for the presence or absence of nasal bone regardless of approach. The ductus venosus can be easily identified by its accelerated flow velocity on color Doppler and then interrogated with pulsed Doppler to assess its flow characteristics. The triphasic waveform of the ductus venosus, reflecting the phases of the cardiac cycle, normally has forward flow toward the heart at all times; a reversed a-wave, corresponding to retrograde flow during atrial contraction, is abnormal. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. US Pregnant Uterus Transvaginal Transvaginal US may be utilized for first trimester aneuploidy screening if optimal views of the nuchal translucency cannot be obtained using the transabdominal approach, which occurs in about 5% of patients [5,24,28]. The higher resolution of transvaginal US can be particularly helpful when imaging women with high body mass indexes. The transvaginal approach may also be favored in patients with multiple abdominal surgeries or presenting with a transverse fetal lie in the lower aspect of the uterus. However, reduced probe mobility limits the available image planes, so using a combination of transabdominal and transvaginal US may be necessary to fully assess the first trimester fetus. Fetal nuchal translucency measurements are similar whether measured by transabdominal or transvaginal US as long as the same principles for image acquisition and nuchal translucency measurement are applied [29]. The transvaginal approach may produce better quality images to assess the nasal bone than transabdominal US [65]. However, perhaps because of the restricted range of movement, a 3-fold higher failure of nasal bone imaging has been reported with transvaginal US [30]. If there is difficulty obtaining the nuchal translucency measurement, there is likely to be difficulty in obtaining the proper image to assess for the presence or absence of nasal bone regardless of approach. The ductus venosus can be easily identified by its accelerated flow velocity on color Doppler and then interrogated with pulsed Doppler to assess its flow characteristics. The triphasic waveform of the ductus venosus, reflecting the phases of the cardiac cycle, normally has forward flow toward the heart at all times; a reversed a-wave, corresponding to retrograde flow during atrial contraction, is abnormal. | 3102397 |
acrac_3102397_4 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | Although the cause of this abnormality in fetal aneuploidy is uncertain, a reversed a-wave is seen in 3% to 4% of euploid fetuses compared to about 70% of trisomy 21 and trisomy 18, 65% of trisomy 13, and 75% of Turner syndrome fetuses [34]. The addition of ductus venosus Doppler assessment to nuchal translucency measurement improves the detection rate of trisomy 21 to 96% with 3% false positive rate [34]. Ductus venosus a-wave abnormalities are also associated with congenital heart disease [35]. In chromosomally normal fetuses with an increased nuchal translucency, a reversed a-wave in the ductus venosus is associated with a 3-fold increase in the likelihood of a major heart anomaly; a normal ductus Nuchal Translucency Evaluation Nuchal Translucency Evaluation The risk of an adverse pregnancy outcome is proportional to the degree of nuchal translucency enlargement; there is an increased risk of intrauterine demise in fetuses with large nuchal translucencies, even in the absence of associated chromosomal or structural abnormalities [22,23]. Although there are no studies that specifically address the optimal management of these pregnancies after the initial US evaluation and diagnostic testing, serial fetal surveillance is usually added to routine prenatal care with periodic US examinations to monitor fetal growth and well-being [2,45]. US Pregnant Uterus Transvaginal A transvaginal US may be advantageous in patients with an increased nuchal translucency, particularly if planning to assess for additional first trimester markers of fetal aneuploidy or screen for major anomalies in women with increased body mass indexes, abdominal wall scarring, or fetal positioning in the lower uterus. Fetal nuchal translucency measurements are similar as long as the same principles for image acquisition are applied, so obtaining a transvaginal measurement is not required if transabdominal imaging is satisfactory [29]. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. Although the cause of this abnormality in fetal aneuploidy is uncertain, a reversed a-wave is seen in 3% to 4% of euploid fetuses compared to about 70% of trisomy 21 and trisomy 18, 65% of trisomy 13, and 75% of Turner syndrome fetuses [34]. The addition of ductus venosus Doppler assessment to nuchal translucency measurement improves the detection rate of trisomy 21 to 96% with 3% false positive rate [34]. Ductus venosus a-wave abnormalities are also associated with congenital heart disease [35]. In chromosomally normal fetuses with an increased nuchal translucency, a reversed a-wave in the ductus venosus is associated with a 3-fold increase in the likelihood of a major heart anomaly; a normal ductus Nuchal Translucency Evaluation Nuchal Translucency Evaluation The risk of an adverse pregnancy outcome is proportional to the degree of nuchal translucency enlargement; there is an increased risk of intrauterine demise in fetuses with large nuchal translucencies, even in the absence of associated chromosomal or structural abnormalities [22,23]. Although there are no studies that specifically address the optimal management of these pregnancies after the initial US evaluation and diagnostic testing, serial fetal surveillance is usually added to routine prenatal care with periodic US examinations to monitor fetal growth and well-being [2,45]. US Pregnant Uterus Transvaginal A transvaginal US may be advantageous in patients with an increased nuchal translucency, particularly if planning to assess for additional first trimester markers of fetal aneuploidy or screen for major anomalies in women with increased body mass indexes, abdominal wall scarring, or fetal positioning in the lower uterus. Fetal nuchal translucency measurements are similar as long as the same principles for image acquisition are applied, so obtaining a transvaginal measurement is not required if transabdominal imaging is satisfactory [29]. | 3102397 |
acrac_3102397_5 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | However, high resolution transvaginal US may more clearly identify the amnion and nuchal translucency borders to ensure an accurate maximal measurement in patients with suboptimal transabdominal views. US Echocardiography Fetal An increased nuchal translucency in a dichorionic twin is an indication to obtain a fetal echocardiogram [20]. Performing fetal echocardiography on twins is challenging because of both maternal factors, such as increased body mass index or inability to rest comfortably during a lengthy examination, and fetal factors, such as unfavorable fetal position or limited views due to the presence of a co-twin. Although early fetal echocardiography may be attempted, a standard fetal echocardiogram at 18 to 22 weeks with an expected detection rate of over 80% for major cardiac anomalies is recommended when increased nuchal translucency is detected in dichorionic twins [26,44]. One of the advantages of nuchal translucency screening in dichorionic twins is the ability to perform individual measurements on each fetus and generate fetus-specific risks [45]. The management of a positive screen or an increased nuchal translucency is similar in twins and singletons; genetic counseling, diagnostic testing, and in continuing pregnancies with a history of increased nuchal translucency or diagnosed with fetal aneuploidy, a detailed anatomic survey, and fetal echocardiography in the second trimester are recommended. The prevalence of increased nuchal translucency in dichorionic twins with a normal karyotype is similar to that in singletons [56]. Although an individual risk can be estimated for each twin and a patient may opt for only sampling the twin suspected to be at risk, it is customary to sample both twins at the time of diagnostic testing to avoid a missed diagnosis because of averaged maternal biochemistries or incorrect assignment of chorionicity [57]. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. However, high resolution transvaginal US may more clearly identify the amnion and nuchal translucency borders to ensure an accurate maximal measurement in patients with suboptimal transabdominal views. US Echocardiography Fetal An increased nuchal translucency in a dichorionic twin is an indication to obtain a fetal echocardiogram [20]. Performing fetal echocardiography on twins is challenging because of both maternal factors, such as increased body mass index or inability to rest comfortably during a lengthy examination, and fetal factors, such as unfavorable fetal position or limited views due to the presence of a co-twin. Although early fetal echocardiography may be attempted, a standard fetal echocardiogram at 18 to 22 weeks with an expected detection rate of over 80% for major cardiac anomalies is recommended when increased nuchal translucency is detected in dichorionic twins [26,44]. One of the advantages of nuchal translucency screening in dichorionic twins is the ability to perform individual measurements on each fetus and generate fetus-specific risks [45]. The management of a positive screen or an increased nuchal translucency is similar in twins and singletons; genetic counseling, diagnostic testing, and in continuing pregnancies with a history of increased nuchal translucency or diagnosed with fetal aneuploidy, a detailed anatomic survey, and fetal echocardiography in the second trimester are recommended. The prevalence of increased nuchal translucency in dichorionic twins with a normal karyotype is similar to that in singletons [56]. Although an individual risk can be estimated for each twin and a patient may opt for only sampling the twin suspected to be at risk, it is customary to sample both twins at the time of diagnostic testing to avoid a missed diagnosis because of averaged maternal biochemistries or incorrect assignment of chorionicity [57]. | 3102397 |
acrac_3102397_6 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | For those who decline diagnostic testing, an evaluation for additional first trimester markers of fetal aneuploidy such as the presence or absence of the nasal bone may assist in patient counseling; however, nasal bone assessment is more challenging in twin pregnancies [58]. Nuchal Translucency Evaluation After the second trimester anatomy survey and fetal echocardiogram, there are no robust evidence-based recommendations for the US follow-up of dichorionic twins with increased nuchal translucency. However, given the risk for intrauterine demise, it is reasonable that serial surveillance of fetal growth and well-being be performed in the third trimester [45,59,60]. US Pregnant Uterus Transvaginal As in singleton pregnancies, transvaginal US can be utilized at 11 to 14 weeks of gestation to assess the nuchal translucency, additional markers of aneuploidy, as well as early fetal anatomy in dichorionic twins. Fetal nuchal translucency measurements are similar as long as the same principles for image acquisition and measurement are employed [29]. Given the larger uterine dimensions from the presence of two fetuses, two sacs of amniotic fluid, and two placentas, a combination of both transabdominal and transvaginal imaging may be optimal to fully assess dichorionic twins with increased nuchal translucency. Variant 4: Increased nuchal translucency in monochorionic twins at 11 to 14 weeks of gestation. US Duplex Doppler Pregnant Uterus The detection of abnormal flow across the tricuspid valve or in the ductus venosus by color and pulsed Doppler increases the likelihood of fetal aneuploidy in monochorionic twins with increased nuchal translucency. In addition, both reversed or absent a-waves in the ductus venosus have been reported to be markers for congenital heart disease and the development of twin-twin transfusion syndrome later in gestation [61,62]. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. For those who decline diagnostic testing, an evaluation for additional first trimester markers of fetal aneuploidy such as the presence or absence of the nasal bone may assist in patient counseling; however, nasal bone assessment is more challenging in twin pregnancies [58]. Nuchal Translucency Evaluation After the second trimester anatomy survey and fetal echocardiogram, there are no robust evidence-based recommendations for the US follow-up of dichorionic twins with increased nuchal translucency. However, given the risk for intrauterine demise, it is reasonable that serial surveillance of fetal growth and well-being be performed in the third trimester [45,59,60]. US Pregnant Uterus Transvaginal As in singleton pregnancies, transvaginal US can be utilized at 11 to 14 weeks of gestation to assess the nuchal translucency, additional markers of aneuploidy, as well as early fetal anatomy in dichorionic twins. Fetal nuchal translucency measurements are similar as long as the same principles for image acquisition and measurement are employed [29]. Given the larger uterine dimensions from the presence of two fetuses, two sacs of amniotic fluid, and two placentas, a combination of both transabdominal and transvaginal imaging may be optimal to fully assess dichorionic twins with increased nuchal translucency. Variant 4: Increased nuchal translucency in monochorionic twins at 11 to 14 weeks of gestation. US Duplex Doppler Pregnant Uterus The detection of abnormal flow across the tricuspid valve or in the ductus venosus by color and pulsed Doppler increases the likelihood of fetal aneuploidy in monochorionic twins with increased nuchal translucency. In addition, both reversed or absent a-waves in the ductus venosus have been reported to be markers for congenital heart disease and the development of twin-twin transfusion syndrome later in gestation [61,62]. | 3102397 |
acrac_3102397_7 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | Although Doppler imaging is likely of little to no value in uncomplicated monochorionic twins, serial assessment of the ductus venosus, umbilical artery and vein, and middle cerebral artery may be useful in cases complicated by unequal placental sharing, twin- twin transfusion syndrome, or twin anemia polycythemia sequence [45]. US Echocardiography Fetal Because of the substantial risk of congenital heart disease, there is strong evidence to support the use of fetal echocardiography for all monochorionic twins, regardless of the nuchal translucency measurement [20]. The overall risk of congenital heart disease in monochorionic twins is 2%, double the background risk of a singleton, and increases to 5% in cases of twin-twin transfusion syndrome, particularly among recipient twins [63]. Recipient twins often demonstrate evidence of volume overload with increased pulmonary and aortic velocities, cardiomegaly, and atrioventricular regurgitation, which, over time, can result in biventricular hypertrophy and diastolic dysfunction [64]. Poor right ventricular systolic function can lead to functional right ventricular outflow tract obstruction in up to 10% of recipient twins, which may progress to severe pulmonic stenosis and a poor prognosis [64]. In contrast, recipient twins with normal cardiac function have improved survival [65]. Therefore, in addition to excluding structural heart defects in monochorionic twins, fetal echocardiography with a detailed functional assessment may be useful in identifying cases of twin-twin transfusion syndrome that would benefit from fetoscopic laser therapy and in evaluating the response to treatment. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. Although Doppler imaging is likely of little to no value in uncomplicated monochorionic twins, serial assessment of the ductus venosus, umbilical artery and vein, and middle cerebral artery may be useful in cases complicated by unequal placental sharing, twin- twin transfusion syndrome, or twin anemia polycythemia sequence [45]. US Echocardiography Fetal Because of the substantial risk of congenital heart disease, there is strong evidence to support the use of fetal echocardiography for all monochorionic twins, regardless of the nuchal translucency measurement [20]. The overall risk of congenital heart disease in monochorionic twins is 2%, double the background risk of a singleton, and increases to 5% in cases of twin-twin transfusion syndrome, particularly among recipient twins [63]. Recipient twins often demonstrate evidence of volume overload with increased pulmonary and aortic velocities, cardiomegaly, and atrioventricular regurgitation, which, over time, can result in biventricular hypertrophy and diastolic dysfunction [64]. Poor right ventricular systolic function can lead to functional right ventricular outflow tract obstruction in up to 10% of recipient twins, which may progress to severe pulmonic stenosis and a poor prognosis [64]. In contrast, recipient twins with normal cardiac function have improved survival [65]. Therefore, in addition to excluding structural heart defects in monochorionic twins, fetal echocardiography with a detailed functional assessment may be useful in identifying cases of twin-twin transfusion syndrome that would benefit from fetoscopic laser therapy and in evaluating the response to treatment. | 3102397 |
acrac_3102397_8 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | Although an increased nuchal translucency may prompt early echocardiography in monochorionic twins, standard second trimester fetal echocardiography is warranted in all monochorionic twins because of the substantial risk of both structural and functional heart abnormalities regardless of the nuchal translucency measurements [59,65]. US Pregnant Uterus Transabdominal First trimester combined screening with nuchal translucency and maternal serum markers is currently a common choice for aneuploidy screening in monochorionic twins [53,54]. In monochorionic twins, each fetus is assumed to have the same risk of aneuploidy equivalent to the maternal age risk of a singleton. Therefore, aneuploidy risk estimates for trisomy 21, 18, and 13 are calculated using the mean nuchal translucency measurement of the twins, usually obtained via transabdominal US. Overall, first trimester combined screening in monochorionic twins provides detection rates of fetal aneuploidy similar to that reported in singletons but with a higher false positive rate [11,53]. A meta-analysis of first trimester combined aneuploidy screening reported a sensitivity of 87.4% for monochorionic twins compared to 86.2% for dichorionic twins [54]. Nuchal translucency measurements have been observed to be higher in monochorionic twins compared to dichorionic twins, which may explain the higher false- positive rate of aneuploidy screening in monochorionic twin pregnancies. In monochorionic twins with increased nuchal translucency thickness, an assessment for additional first trimester markers of fetal aneuploidy, such as the absence of the nasal bone, may be helpful to patients trying to decide whether to undergo invasive diagnostic testing [58]. Increased nuchal translucency thickness in a monochorionic twin may also be an early manifestation of inter- fetal transfusion and early hypervolemic congestion in a recipient twin. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. Although an increased nuchal translucency may prompt early echocardiography in monochorionic twins, standard second trimester fetal echocardiography is warranted in all monochorionic twins because of the substantial risk of both structural and functional heart abnormalities regardless of the nuchal translucency measurements [59,65]. US Pregnant Uterus Transabdominal First trimester combined screening with nuchal translucency and maternal serum markers is currently a common choice for aneuploidy screening in monochorionic twins [53,54]. In monochorionic twins, each fetus is assumed to have the same risk of aneuploidy equivalent to the maternal age risk of a singleton. Therefore, aneuploidy risk estimates for trisomy 21, 18, and 13 are calculated using the mean nuchal translucency measurement of the twins, usually obtained via transabdominal US. Overall, first trimester combined screening in monochorionic twins provides detection rates of fetal aneuploidy similar to that reported in singletons but with a higher false positive rate [11,53]. A meta-analysis of first trimester combined aneuploidy screening reported a sensitivity of 87.4% for monochorionic twins compared to 86.2% for dichorionic twins [54]. Nuchal translucency measurements have been observed to be higher in monochorionic twins compared to dichorionic twins, which may explain the higher false- positive rate of aneuploidy screening in monochorionic twin pregnancies. In monochorionic twins with increased nuchal translucency thickness, an assessment for additional first trimester markers of fetal aneuploidy, such as the absence of the nasal bone, may be helpful to patients trying to decide whether to undergo invasive diagnostic testing [58]. Increased nuchal translucency thickness in a monochorionic twin may also be an early manifestation of inter- fetal transfusion and early hypervolemic congestion in a recipient twin. | 3102397 |
acrac_3102397_9 | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age | Indeed, both nuchal translucency abnormalities and crown-rump length discrepancies have been associated with an increased risk of twin-twin Nuchal Translucency Evaluation transfusion syndrome [66-68]. A crown-rump discrepancy of >10% is associated with almost a doubling the risk of developing twin-twin transfusion syndrome [67,68]. Nuchal translucency discordance >20% has been associated with a >30% risk of severe twin-twin transfusion syndrome and early fetal death compared with a <10% risk when the discordance is <20% [69]. As in singletons and dichorionic twins, an increased nuchal translucency in monochorionic twins is associated with fetal aneuploidy, genetic syndromes, structural anomalies, and intrauterine demise. Genetic counseling, invasive diagnostic testing, fetal anatomic surveys, and fetal echocardiography are recommended in monochorionic twin pregnancies complicated by increased nuchal translucency thickness affecting one or both twins. Serial US surveillance of monochorionic twins is advised because of complications associated with sharing a single placenta such as twin-twin transfusion syndrome, unequal placental sharing with discordant twin growth and selective intrauterine growth restriction, and twin anemia polycythemia sequence [64,70]. Because of these unique complications, women with monochorionic pregnancies are followed more closely than dichorionic pregnancies; serial US evaluations every 2 weeks starting at 16 weeks until delivery should be considered [45]. Despite its potential value, a recent review concluded that it is not currently possible to predict adverse outcomes in monochorionic twin pregnancies based on nuchal translucency assessment alone [71]. | Nuchal Translucency Evaluation at 11 to 14 Weeks Gestational Age. Indeed, both nuchal translucency abnormalities and crown-rump length discrepancies have been associated with an increased risk of twin-twin Nuchal Translucency Evaluation transfusion syndrome [66-68]. A crown-rump discrepancy of >10% is associated with almost a doubling the risk of developing twin-twin transfusion syndrome [67,68]. Nuchal translucency discordance >20% has been associated with a >30% risk of severe twin-twin transfusion syndrome and early fetal death compared with a <10% risk when the discordance is <20% [69]. As in singletons and dichorionic twins, an increased nuchal translucency in monochorionic twins is associated with fetal aneuploidy, genetic syndromes, structural anomalies, and intrauterine demise. Genetic counseling, invasive diagnostic testing, fetal anatomic surveys, and fetal echocardiography are recommended in monochorionic twin pregnancies complicated by increased nuchal translucency thickness affecting one or both twins. Serial US surveillance of monochorionic twins is advised because of complications associated with sharing a single placenta such as twin-twin transfusion syndrome, unequal placental sharing with discordant twin growth and selective intrauterine growth restriction, and twin anemia polycythemia sequence [64,70]. Because of these unique complications, women with monochorionic pregnancies are followed more closely than dichorionic pregnancies; serial US evaluations every 2 weeks starting at 16 weeks until delivery should be considered [45]. Despite its potential value, a recent review concluded that it is not currently possible to predict adverse outcomes in monochorionic twin pregnancies based on nuchal translucency assessment alone [71]. | 3102397 |
acrac_3082594_0 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | Introduction/Background Transcatheter aortic valve replacement (TAVR) has dramatically impacted the management of high-risk surgical patients [1-10], as well as medium- and low-risk patients [11], for the treatment of aortic valve disease. TAVR is a less invasive route (percutaneous endovascular) to position a prosthesis at the aortic annulus that displaces the native aortic valve leaflets toward the aortic wall. Procedure-related complications [3,5,7,8] are linked to inaccurate estimates of annular geometry; unlike surgical aortic valve replacement, the aortic annulus is not directly inspected by the proceduralist at the time of the procedure, and multiple parameters related to the annulus should be measured. Because the annulus has a complex geometry, volumetric data have emerged with standardized reformatting along patient-specific anatomic planes for annular assessment and device sizing [1,2,4,9,10,12-26]. Accurate measurements guide optimal choices for device sizing and deployment, with a secondary reduction in TAVR-related complications. The catheter-based system ranges in size between 14 and 24 Fr with transfemoral, transaxillary, and transaortic as well as direct aortic and left ventricular approaches reported; the entire aorta and branches to potential access points are evaluated for the presence, burden, and distribution of peripheral vascular atherosclerosis. This document does not elucidate the diagnosis of aortic valve disease, surgical risk stratification, [27-32] or the assessment of coronary artery disease. It is presumed that patients considered in this document are candidates for TAVR. Also, the panel did not consider planning done at the time of intervention with either catheter angiography, echocardiography, or a combination of both. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. Introduction/Background Transcatheter aortic valve replacement (TAVR) has dramatically impacted the management of high-risk surgical patients [1-10], as well as medium- and low-risk patients [11], for the treatment of aortic valve disease. TAVR is a less invasive route (percutaneous endovascular) to position a prosthesis at the aortic annulus that displaces the native aortic valve leaflets toward the aortic wall. Procedure-related complications [3,5,7,8] are linked to inaccurate estimates of annular geometry; unlike surgical aortic valve replacement, the aortic annulus is not directly inspected by the proceduralist at the time of the procedure, and multiple parameters related to the annulus should be measured. Because the annulus has a complex geometry, volumetric data have emerged with standardized reformatting along patient-specific anatomic planes for annular assessment and device sizing [1,2,4,9,10,12-26]. Accurate measurements guide optimal choices for device sizing and deployment, with a secondary reduction in TAVR-related complications. The catheter-based system ranges in size between 14 and 24 Fr with transfemoral, transaxillary, and transaortic as well as direct aortic and left ventricular approaches reported; the entire aorta and branches to potential access points are evaluated for the presence, burden, and distribution of peripheral vascular atherosclerosis. This document does not elucidate the diagnosis of aortic valve disease, surgical risk stratification, [27-32] or the assessment of coronary artery disease. It is presumed that patients considered in this document are candidates for TAVR. Also, the panel did not consider planning done at the time of intervention with either catheter angiography, echocardiography, or a combination of both. | 3082594 |
acrac_3082594_1 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | For this document, the panel only considered the 2 clinical tasks required for preprocedure screening: (Variant 1) assessment of aortic annulus and aortic root, to help guide the choice of the valve prosthesis, and (Variant 2) assessment of supravalvular aorta and vascular access for potential determination of vascular access site and road mapping the desired device delivery. Special Imaging Considerations For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [33]: 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. aMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. bResearch Author, South Texas Radiology Group, P.A., San Antonio, Texas. cUniversity of Michigan, Ann Arbor, Michigan. dPanel Chair, Brigham & Women's Hospital, Boston, Massachusetts. ePanel Chair, Cleveland Clinic, Cleveland, Ohio. fPanel Vice-Chair, Mayo Clinic, Rochester, Minnesota. gKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. hSanger Heart and Vascular Institute, Charlotte, North Carolina; American Society of Echocardiography. iUT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging. jUniversity of Washington School of Medicine, Seattle, Washington; Society for Cardiovascular Magnetic Resonance. kEmory University, Atlanta, Georgia; Committee on Emergency Radiology-GSER. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. For this document, the panel only considered the 2 clinical tasks required for preprocedure screening: (Variant 1) assessment of aortic annulus and aortic root, to help guide the choice of the valve prosthesis, and (Variant 2) assessment of supravalvular aorta and vascular access for potential determination of vascular access site and road mapping the desired device delivery. Special Imaging Considerations For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [33]: 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. aMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. bResearch Author, South Texas Radiology Group, P.A., San Antonio, Texas. cUniversity of Michigan, Ann Arbor, Michigan. dPanel Chair, Brigham & Women's Hospital, Boston, Massachusetts. ePanel Chair, Cleveland Clinic, Cleveland, Ohio. fPanel Vice-Chair, Mayo Clinic, Rochester, Minnesota. gKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. hSanger Heart and Vascular Institute, Charlotte, North Carolina; American Society of Echocardiography. iUT Southwestern Medical Center, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging. jUniversity of Washington School of Medicine, Seattle, Washington; Society for Cardiovascular Magnetic Resonance. kEmory University, Atlanta, Georgia; Committee on Emergency Radiology-GSER. | 3082594 |
acrac_3082594_2 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | lWashington University School of Medicine, Saint Louis, Missouri; American Association for Thoracic Surgery. mCleveland Clinic, Cleveland, Ohio. nStanford University, Stanford, California. oMercyhealth, Rockford, Illinois. pSpecialty Chair, Duke University Medical Center, Durham, North Carolina. qSpecialty Chair, Brigham & Women's Hospital, Boston, Massachusetts. 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] Transcatheter Aortic Valve Replacement Imaging should allow characterization and reporting of aortic valve morphology in each patient and degree of calcification [34,35]. Calcified raphe for bicuspid valves and excess leaflet calcification are known to be associated with an increased risk of procedural complications and midterm mortality [36]. The annulus size for bicuspid aortic valve should be measured and reported in the same fashion as for tricuspid aortic valves, even though the basal attachments of the 2 leaflets of bicuspid aortic valve provide only 2 landmarks out of a necessary 3 landmarks to define an annular plane in space [37]. In addition, it is important to evaluate coronary ostial heights, sinus of Valsalva widths, sinotubular junction diameters, and annular/left ventricular outflow tract (LVOT) calcification, all of which are predictive of complication risks with TAVR. OR Discussion of Procedures by Variant Variant 1: Preintervention planning for transcatheter aortic valve replacement: assessment of aortic root. Initial imaging. Aortography Chest There is no relevant literature to support the use of aortography chest for annulus sizing and assessment of aortic root. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. lWashington University School of Medicine, Saint Louis, Missouri; American Association for Thoracic Surgery. mCleveland Clinic, Cleveland, Ohio. nStanford University, Stanford, California. oMercyhealth, Rockford, Illinois. pSpecialty Chair, Duke University Medical Center, Durham, North Carolina. qSpecialty Chair, Brigham & Women's Hospital, Boston, Massachusetts. 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] Transcatheter Aortic Valve Replacement Imaging should allow characterization and reporting of aortic valve morphology in each patient and degree of calcification [34,35]. Calcified raphe for bicuspid valves and excess leaflet calcification are known to be associated with an increased risk of procedural complications and midterm mortality [36]. The annulus size for bicuspid aortic valve should be measured and reported in the same fashion as for tricuspid aortic valves, even though the basal attachments of the 2 leaflets of bicuspid aortic valve provide only 2 landmarks out of a necessary 3 landmarks to define an annular plane in space [37]. In addition, it is important to evaluate coronary ostial heights, sinus of Valsalva widths, sinotubular junction diameters, and annular/left ventricular outflow tract (LVOT) calcification, all of which are predictive of complication risks with TAVR. OR Discussion of Procedures by Variant Variant 1: Preintervention planning for transcatheter aortic valve replacement: assessment of aortic root. Initial imaging. Aortography Chest There is no relevant literature to support the use of aortography chest for annulus sizing and assessment of aortic root. | 3082594 |
acrac_3082594_3 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with intravenous (IV) contrast for annulus sizing and assessment of aortic root. CT Chest Without and With IV Contrast There is no literature in support of chest CT without and with IV contrast for annular sizing and assessment of aortic root. CT Chest Without IV Contrast There is no literature in support of chest CT without IV contrast for annular sizing and assessment of aortic root. Aortic calcification can; however, be assessed on CT chest without IV contrast. Harbaoui et al [38] evaluated ascending aortic calcifications in 189 patients undergoing TAVR and noted ascending aortic calcification (tertile 3 versus tertile 1) appeared predictive of heart failure (hazard ratio [HR]: 2.29; 95% confidence interval [CI], 1.12- 4.66; P = . 023). Transcatheter Aortic Valve Replacement (14% versus 35%; P = . 003). In a prospective study of 266 patients, 133 consecutive patients underwent TAVR with valve prosthesis size recommendation based on a CTA sizing algorithm and were compared with another cohort of 133 consecutive patients who underwent TAVR with valve prosthesis size recommendation based on a combination of echocardiogram measurements and angiographic images. The authors demonstrated a significant reduction in the incidence of paravalvular leak of 5.3% (7/133) in the CT group and 12.8% (17/133) in the control group (P = . 032) as a primary endpoint and aortic annulus rupture, and they demonstrated a significant reduction in in-hospital deaths of 3.8% (5/133) in the CTA group and 11.3% (15/133) in the control group (P = . 02) as a secondary endpoint [15]. CTA Chest With IV Contrast There is no literature to support the use of CTA chest with IV contrast for the assessment of the aortic root; however, in absence of motion artifacts, the annulus can be evaluated for size, calcifications, coronary ostial heights, and sinus of Valsalva diameters. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. CT Chest With IV Contrast There is no relevant literature to support the use of chest CT with intravenous (IV) contrast for annulus sizing and assessment of aortic root. CT Chest Without and With IV Contrast There is no literature in support of chest CT without and with IV contrast for annular sizing and assessment of aortic root. CT Chest Without IV Contrast There is no literature in support of chest CT without IV contrast for annular sizing and assessment of aortic root. Aortic calcification can; however, be assessed on CT chest without IV contrast. Harbaoui et al [38] evaluated ascending aortic calcifications in 189 patients undergoing TAVR and noted ascending aortic calcification (tertile 3 versus tertile 1) appeared predictive of heart failure (hazard ratio [HR]: 2.29; 95% confidence interval [CI], 1.12- 4.66; P = . 023). Transcatheter Aortic Valve Replacement (14% versus 35%; P = . 003). In a prospective study of 266 patients, 133 consecutive patients underwent TAVR with valve prosthesis size recommendation based on a CTA sizing algorithm and were compared with another cohort of 133 consecutive patients who underwent TAVR with valve prosthesis size recommendation based on a combination of echocardiogram measurements and angiographic images. The authors demonstrated a significant reduction in the incidence of paravalvular leak of 5.3% (7/133) in the CT group and 12.8% (17/133) in the control group (P = . 032) as a primary endpoint and aortic annulus rupture, and they demonstrated a significant reduction in in-hospital deaths of 3.8% (5/133) in the CTA group and 11.3% (15/133) in the control group (P = . 02) as a secondary endpoint [15]. CTA Chest With IV Contrast There is no literature to support the use of CTA chest with IV contrast for the assessment of the aortic root; however, in absence of motion artifacts, the annulus can be evaluated for size, calcifications, coronary ostial heights, and sinus of Valsalva diameters. | 3082594 |
acrac_3082594_4 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | CTA Coronary Arteries With IV Contrast There is no relevant literature to support the use of CTA coronary arteries with IV contrast as the initial imaging modality for the assessment of aortic root. Although CTA coronary arteries with IV contrast can evaluate coronary anatomy and stenosis, which can be helpful in the management of patients undergoing TAVR, it does not impact selection of device type and/or size. A multiphase coronary CTA can also be used for evaluation and sizing of the annulus and aortic root. MRA Chest With IV Contrast Although a majority of the evidence focuses on noncontrast MR angiography (MRA) techniques for root assessment, contrast-enhanced MRA may provide faster acquisition [45]. MRA Chest Without and With IV Contrast In a prospective study of 69 patients, Ruile et al [46] observed good reproducibility of aortic annulus dimensions and calcifications in comparison with cardiac CTA, even in the presence of arrhythmias in the all-comers pre-TAVR population and useful in patients at an increased risk for contrast-induced nephropathy with an agreement for hypothetical prosthesis sizing in 63 of 67 (94%) patients for systolic CTA and modeled systolic MRA. Also, excellent correlation was reported for the distance to the right or left coronary ostium between diastolic CTA and diastolic MRA. The role of MRA is; however, limited when there is a high-susceptibility artifact, magnetic field incompatible devices, and severe arrhythmia. Finally, the MRA examination is a technically more complex examination, with longer study time and a higher required degree of patient cooperation, which can be problematic for patients with a poor clinical condition [47]. MRA Coronary Arteries Without and With IV Contrast There is no relevant literature to support the use of MRA coronary arteries without and with IV contrast as the initial imaging modality for the assessment of aortic root. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. CTA Coronary Arteries With IV Contrast There is no relevant literature to support the use of CTA coronary arteries with IV contrast as the initial imaging modality for the assessment of aortic root. Although CTA coronary arteries with IV contrast can evaluate coronary anatomy and stenosis, which can be helpful in the management of patients undergoing TAVR, it does not impact selection of device type and/or size. A multiphase coronary CTA can also be used for evaluation and sizing of the annulus and aortic root. MRA Chest With IV Contrast Although a majority of the evidence focuses on noncontrast MR angiography (MRA) techniques for root assessment, contrast-enhanced MRA may provide faster acquisition [45]. MRA Chest Without and With IV Contrast In a prospective study of 69 patients, Ruile et al [46] observed good reproducibility of aortic annulus dimensions and calcifications in comparison with cardiac CTA, even in the presence of arrhythmias in the all-comers pre-TAVR population and useful in patients at an increased risk for contrast-induced nephropathy with an agreement for hypothetical prosthesis sizing in 63 of 67 (94%) patients for systolic CTA and modeled systolic MRA. Also, excellent correlation was reported for the distance to the right or left coronary ostium between diastolic CTA and diastolic MRA. The role of MRA is; however, limited when there is a high-susceptibility artifact, magnetic field incompatible devices, and severe arrhythmia. Finally, the MRA examination is a technically more complex examination, with longer study time and a higher required degree of patient cooperation, which can be problematic for patients with a poor clinical condition [47]. MRA Coronary Arteries Without and With IV Contrast There is no relevant literature to support the use of MRA coronary arteries without and with IV contrast as the initial imaging modality for the assessment of aortic root. | 3082594 |
acrac_3082594_5 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | Transcatheter Aortic Valve Replacement MRA Coronary Arteries Without IV Contrast There is no relevant literature to support the use of MRA coronary arteries without IV contrast as the initial imaging modality for the assessment of aortic root. Transcatheter Aortic Valve Replacement US Echocardiography Transesophageal In a retrospective analysis of 101 patients who underwent both preoperative MDCT and 3-D TEE for aortic annulus sizing for TAVR planning, the automatic software measurements showed very good agreement with manual values obtained using MDCT and 3-D TEE, with the interactive approach having slightly narrower limits of agreement. The latter also had excellent intra- and interobserver variability. Both fully automatic and interactive analyses showed excellent test-retest reproducibility, with the first having a faster analysis time. Finally, either approach led to good sizing agreement against the true implanted sizes (>77%) and against MDCT-based sizes (>88%) [53]. A retrospective analysis of 31 patients who underwent transcatheter aortic valve implantation showed an excellent correlation between the aortic annulus measurements obtained by both manual 3-D TEE method and by the automatic software method (intraclass correlation coefficient: 0.731 (0.508-0.862), r: 0.742) for aortic annulus diameter and (intraclass correlation coefficient: 0.723 (0.662-0.923), r: 0.723) for the aortic annulus area, with no significant differences regardless of the method used. The interobserver variability was superior for the automatic measurements than for the manual ones. In a subgroup of 10 patients, they also found an excellent correlation between the automatic measurements and those obtained by MDCT (intraclass correlation coefficient: 0.941 (0.761- 0.985), r: 0.901) for aortic annulus diameter and (intraclass correlation coefficient: 0.853 (0.409-0.964), r: 0.744) for the aortic annulus area. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. Transcatheter Aortic Valve Replacement MRA Coronary Arteries Without IV Contrast There is no relevant literature to support the use of MRA coronary arteries without IV contrast as the initial imaging modality for the assessment of aortic root. Transcatheter Aortic Valve Replacement US Echocardiography Transesophageal In a retrospective analysis of 101 patients who underwent both preoperative MDCT and 3-D TEE for aortic annulus sizing for TAVR planning, the automatic software measurements showed very good agreement with manual values obtained using MDCT and 3-D TEE, with the interactive approach having slightly narrower limits of agreement. The latter also had excellent intra- and interobserver variability. Both fully automatic and interactive analyses showed excellent test-retest reproducibility, with the first having a faster analysis time. Finally, either approach led to good sizing agreement against the true implanted sizes (>77%) and against MDCT-based sizes (>88%) [53]. A retrospective analysis of 31 patients who underwent transcatheter aortic valve implantation showed an excellent correlation between the aortic annulus measurements obtained by both manual 3-D TEE method and by the automatic software method (intraclass correlation coefficient: 0.731 (0.508-0.862), r: 0.742) for aortic annulus diameter and (intraclass correlation coefficient: 0.723 (0.662-0.923), r: 0.723) for the aortic annulus area, with no significant differences regardless of the method used. The interobserver variability was superior for the automatic measurements than for the manual ones. In a subgroup of 10 patients, they also found an excellent correlation between the automatic measurements and those obtained by MDCT (intraclass correlation coefficient: 0.941 (0.761- 0.985), r: 0.901) for aortic annulus diameter and (intraclass correlation coefficient: 0.853 (0.409-0.964), r: 0.744) for the aortic annulus area. | 3082594 |
acrac_3082594_6 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | Thus, new automatic 3-D TEE software allows modeling and quantifying the aortic root from 3-D TEE data with high reproducibility and showed good correlation between the automated measurements and other 3-D validated techniques, thus supporting its use in clinical practice as an alternative to MDCT before transcatheter aortic valve implantation for annular sizing (annular area, annular mean diameter and perimeter, sinotubular junction diameter, sinus of Valsalva diameter) [54]. Although TEE can be used intraprocedurally, it has a limited role for preprocedural assessment. Additionally there is a paucity of TEE data for evaluating aortic root features such as coronary ostial height and subannular calcification [55]. US Echocardiography Transthoracic Resting Although ultrasound (US) echocardiography transthoracic resting can diagnose aortic stenosis and can be used during TAVR procedures, there is no relevant literature to support its use for annulus sizing and assessment of aortic root. Variant 2: Preintervention planning for transcatheter aortic valve replacement: assessment of supravalvular aorta and vascular access. Initial imaging. Aortography Chest, Abdomen, and Pelvis There is no relevant literature to support the use of aortography of the chest, abdomen, and pelvis as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Abdomen and Pelvis With IV Contrast There is no relevant literature to support the use of CT abdomen and pelvis with IV contrast as the initial imaging modality for the valuation of vascular access for a TAVR procedure. 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 as the initial imaging modality for evaluation of vascular access for a TAVR procedure. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. Thus, new automatic 3-D TEE software allows modeling and quantifying the aortic root from 3-D TEE data with high reproducibility and showed good correlation between the automated measurements and other 3-D validated techniques, thus supporting its use in clinical practice as an alternative to MDCT before transcatheter aortic valve implantation for annular sizing (annular area, annular mean diameter and perimeter, sinotubular junction diameter, sinus of Valsalva diameter) [54]. Although TEE can be used intraprocedurally, it has a limited role for preprocedural assessment. Additionally there is a paucity of TEE data for evaluating aortic root features such as coronary ostial height and subannular calcification [55]. US Echocardiography Transthoracic Resting Although ultrasound (US) echocardiography transthoracic resting can diagnose aortic stenosis and can be used during TAVR procedures, there is no relevant literature to support its use for annulus sizing and assessment of aortic root. Variant 2: Preintervention planning for transcatheter aortic valve replacement: assessment of supravalvular aorta and vascular access. Initial imaging. Aortography Chest, Abdomen, and Pelvis There is no relevant literature to support the use of aortography of the chest, abdomen, and pelvis as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Abdomen and Pelvis With IV Contrast There is no relevant literature to support the use of CT abdomen and pelvis with IV contrast as the initial imaging modality for the valuation of vascular access for a TAVR procedure. 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 as the initial imaging modality for evaluation of vascular access for a TAVR procedure. | 3082594 |
acrac_3082594_7 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | CT Abdomen and Pelvis Without IV Contrast CT abdomen and pelvis without IV contrast cannot assess lumen size and patency, but mural calcifications can be assessed. In a comparative study of 103 of 588 patients undergoing both noncontrast CT and angiography, with 17 sheath-related complications, Okuyama et al [23] showed there was no difference between noncontrast CT and angiography: area under the curve 0.79 (95% CI, 0.70-0.86) versus area under the curve 0.73 (95% CI, 0.63-0.81) in predicting sheath-related complications. CT Chest, Abdomen, and Pelvis With IV Contrast There is no relevant literature to support the use of CT chest, abdomen, and pelvis with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature to support the use of CT chest, abdomen, and pelvis without and with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. Aortic calcification can: however, be assessed on CT chest, abdomen, and pelvis without and with IV contrast. Harbaoui et al [38] evaluated 189 patients undergoing TAVR for total aortic calcifications, ascending aortic calcification, descending Transcatheter Aortic Valve Replacement aorta calcifications, and abdominal aorta calcifications. In their study, total aortic calcification (tertile 3 versus tertile 1) was significantly and strongly associated with cardiac mortality (HR: 16.74; 95% CI, 2.21-127.05; P = . 006) and all-cause mortality (HR: 2.39; 95% CI, 1.18-4.84; P = . 015). Each aortic calcified segment was associated with cardiac mortality, whereas only ascending aortic calcification (tertile 3 versus tertile 1) appeared predictive of heart failure (HR: 2.29; 95% CI, 1.12-4.66; P = . 023). | Preprocedural Planning for Transcatheter Aortic Valve Replacement. CT Abdomen and Pelvis Without IV Contrast CT abdomen and pelvis without IV contrast cannot assess lumen size and patency, but mural calcifications can be assessed. In a comparative study of 103 of 588 patients undergoing both noncontrast CT and angiography, with 17 sheath-related complications, Okuyama et al [23] showed there was no difference between noncontrast CT and angiography: area under the curve 0.79 (95% CI, 0.70-0.86) versus area under the curve 0.73 (95% CI, 0.63-0.81) in predicting sheath-related complications. CT Chest, Abdomen, and Pelvis With IV Contrast There is no relevant literature to support the use of CT chest, abdomen, and pelvis with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Chest, Abdomen, and Pelvis Without and With IV Contrast There is no relevant literature to support the use of CT chest, abdomen, and pelvis without and with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. Aortic calcification can: however, be assessed on CT chest, abdomen, and pelvis without and with IV contrast. Harbaoui et al [38] evaluated 189 patients undergoing TAVR for total aortic calcifications, ascending aortic calcification, descending Transcatheter Aortic Valve Replacement aorta calcifications, and abdominal aorta calcifications. In their study, total aortic calcification (tertile 3 versus tertile 1) was significantly and strongly associated with cardiac mortality (HR: 16.74; 95% CI, 2.21-127.05; P = . 006) and all-cause mortality (HR: 2.39; 95% CI, 1.18-4.84; P = . 015). Each aortic calcified segment was associated with cardiac mortality, whereas only ascending aortic calcification (tertile 3 versus tertile 1) appeared predictive of heart failure (HR: 2.29; 95% CI, 1.12-4.66; P = . 023). | 3082594 |
acrac_3082594_8 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | CT Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature to support the use of CT chest, abdomen, and pelvis without IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT chest, abdomen, and pelvis without IV contrast cannot assess lumen size and patency, but mural calcifications can be assessed. CT Chest With IV Contrast There is no relevant literature to support the use of CT chest with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT chest without IV contrast cannot assess lumen size and patency, but mural calcifications can be assessed. Additionally, circumferential aortic calcifications (porcelain aorta) can be detected, which may complicate the device delivery [56]. CT Heart Function and Morphology With IV Contrast There is no relevant literature to support the use of CT heart function and morphology with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. Preprocedural CT heart function and morphology with IV contrast can help in identifying left ventricular apex and assess myocardial thickness and left ventricular orientation and in guiding planned mini-thoracotomy. CTA Abdomen and Pelvis With IV Contrast CTA imaging can assess luminal size, patency, vessel tortuosity, and the extent of mural calcifications. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. CT Chest, Abdomen, and Pelvis Without IV Contrast There is no relevant literature to support the use of CT chest, abdomen, and pelvis without IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT chest, abdomen, and pelvis without IV contrast cannot assess lumen size and patency, but mural calcifications can be assessed. CT Chest With IV Contrast There is no relevant literature to support the use of CT chest with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Chest Without and With IV Contrast There is no relevant literature to support the use of CT chest without and with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT Chest Without IV Contrast There is no relevant literature to support the use of CT chest without IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. CT chest without IV contrast cannot assess lumen size and patency, but mural calcifications can be assessed. Additionally, circumferential aortic calcifications (porcelain aorta) can be detected, which may complicate the device delivery [56]. CT Heart Function and Morphology With IV Contrast There is no relevant literature to support the use of CT heart function and morphology with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. Preprocedural CT heart function and morphology with IV contrast can help in identifying left ventricular apex and assess myocardial thickness and left ventricular orientation and in guiding planned mini-thoracotomy. CTA Abdomen and Pelvis With IV Contrast CTA imaging can assess luminal size, patency, vessel tortuosity, and the extent of mural calcifications. | 3082594 |
acrac_3082594_9 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | Kinnel et al [57] evaluated aortoiliac and femoral arteries in their comparative study of 175 patients for abdominal aortic tortuosity and noted abdominal aorta tortuosity in 28 patients (16%) with strong association with the occurrence of a complication (adjusted odds ratio 2.7; 95% CI, 1.1-6.6; P = . 03). CTA Chest, Abdomen, and Pelvis With IV Contrast CTA allows the assessment of vessel size, calcifications, and minimal luminal diameters [58]. In a comparative study of 283 of 588 patients undergoing both contrast CT and angiography, with 35 sheath-related complications, Okuyama et al [23] showed a greater predictive value for vascular complications with contrast CT than angiography by area under the curve (P < . 001): 0.87 (95% CI, 0.82-0.91) versus 0.72 (95% CI, 0.66-0.77). Recent data from the VICTORY registry of 240 patients also showed a role of CTA in assessing tortuosity. In the study, the authors noted a higher incidence of access and bleeding complications in patients with a higher iliofemoral tortuosity score (56 [36.8%] versus 17 [19.3%]; P = . 003). Additionally, in a multivariate logistic regression analysis, only the higher iliofemoral tortuosity score was a significant predictor of the primary endpoint (odds ratio, 2.11; 95% CI, 1.09-4.05; P = . 026) [59]. CTA can also be used to evaluate alternate access sites like direct aortic or subclavian/axillary access. Arnett et al [60] retrospectively evaluated 208 patients undergoing CTA and reported on the compared axillary arteries and demonstrated substantially lower rates of significant stenosis (2% versus 12%, P < . 01) and significantly lower rates of moderate to severe calcification disease (9% versus 64%, P < . 01) than iliofemoral arteries. CTA Chest With IV Contrast CTA of the chest with IV contrast is helpful for patients undergoing TAVR [49] for the assessment of supravalvular aorta. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. Kinnel et al [57] evaluated aortoiliac and femoral arteries in their comparative study of 175 patients for abdominal aortic tortuosity and noted abdominal aorta tortuosity in 28 patients (16%) with strong association with the occurrence of a complication (adjusted odds ratio 2.7; 95% CI, 1.1-6.6; P = . 03). CTA Chest, Abdomen, and Pelvis With IV Contrast CTA allows the assessment of vessel size, calcifications, and minimal luminal diameters [58]. In a comparative study of 283 of 588 patients undergoing both contrast CT and angiography, with 35 sheath-related complications, Okuyama et al [23] showed a greater predictive value for vascular complications with contrast CT than angiography by area under the curve (P < . 001): 0.87 (95% CI, 0.82-0.91) versus 0.72 (95% CI, 0.66-0.77). Recent data from the VICTORY registry of 240 patients also showed a role of CTA in assessing tortuosity. In the study, the authors noted a higher incidence of access and bleeding complications in patients with a higher iliofemoral tortuosity score (56 [36.8%] versus 17 [19.3%]; P = . 003). Additionally, in a multivariate logistic regression analysis, only the higher iliofemoral tortuosity score was a significant predictor of the primary endpoint (odds ratio, 2.11; 95% CI, 1.09-4.05; P = . 026) [59]. CTA can also be used to evaluate alternate access sites like direct aortic or subclavian/axillary access. Arnett et al [60] retrospectively evaluated 208 patients undergoing CTA and reported on the compared axillary arteries and demonstrated substantially lower rates of significant stenosis (2% versus 12%, P < . 01) and significantly lower rates of moderate to severe calcification disease (9% versus 64%, P < . 01) than iliofemoral arteries. CTA Chest With IV Contrast CTA of the chest with IV contrast is helpful for patients undergoing TAVR [49] for the assessment of supravalvular aorta. | 3082594 |
acrac_3082594_10 | Preprocedural Planning for Transcatheter Aortic Valve Replacement | It has been demonstrated that a subclavian approach leads to morbidity and mortality rates similar to those observed with the transfemoral approach [61]. CTA can also be used to evaluate alternate access sites like direct aortic or subclavian/axillary access. Arnett et al retrospectively evaluated 208 patients undergoing CTA and reported on the compared axillary arteries and demonstrated substantially lower rates of significant stenosis (2% Transcatheter Aortic Valve Replacement versus 12%, P < . 01) and significantly lower rates of moderate to severe calcification disease (9% versus 64%, P < . 01) than iliofemoral arteries [60]. MRA Abdomen and Pelvis Without and With IV Contrast There is limited data supporting MRA abdomen and pelvis without and with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. MRA Chest, Abdomen, and Pelvis With IV Contrast There is no relevant literature supporting the use of MRA chest, abdomen, and pelvis with IV contrast for the assessment of supra ventricular aorta and vascular access. MRA chest, abdomen, and pelvis with IV contrast can; however, be used as an alternate option in a selected patient population to assess supravalvular aorta and vascular access. MRA Chest With and Without IV Contrast There is no relevant literature supporting the use of MRA chest with and without IV contrast for the assessment of supra ventricular aorta and vascular access; however, MRA chest with and without IV contrast can be used as an alternate option in a selected patient population to assess supravalvular aorta and vascular access. US Duplex Doppler Chest, Abdomen, and Pelvis There is no relevant literature to support the use of US duplex doppler chest, abdomen, and pelvis as the initial imaging modality for evaluation of vascular access before a TAVR procedure. | Preprocedural Planning for Transcatheter Aortic Valve Replacement. It has been demonstrated that a subclavian approach leads to morbidity and mortality rates similar to those observed with the transfemoral approach [61]. CTA can also be used to evaluate alternate access sites like direct aortic or subclavian/axillary access. Arnett et al retrospectively evaluated 208 patients undergoing CTA and reported on the compared axillary arteries and demonstrated substantially lower rates of significant stenosis (2% Transcatheter Aortic Valve Replacement versus 12%, P < . 01) and significantly lower rates of moderate to severe calcification disease (9% versus 64%, P < . 01) than iliofemoral arteries [60]. MRA Abdomen and Pelvis Without and With IV Contrast There is limited data supporting MRA abdomen and pelvis without and with IV contrast as the initial imaging modality for the evaluation of vascular access before a TAVR procedure. MRA Chest, Abdomen, and Pelvis With IV Contrast There is no relevant literature supporting the use of MRA chest, abdomen, and pelvis with IV contrast for the assessment of supra ventricular aorta and vascular access. MRA chest, abdomen, and pelvis with IV contrast can; however, be used as an alternate option in a selected patient population to assess supravalvular aorta and vascular access. MRA Chest With and Without IV Contrast There is no relevant literature supporting the use of MRA chest with and without IV contrast for the assessment of supra ventricular aorta and vascular access; however, MRA chest with and without IV contrast can be used as an alternate option in a selected patient population to assess supravalvular aorta and vascular access. US Duplex Doppler Chest, Abdomen, and Pelvis There is no relevant literature to support the use of US duplex doppler chest, abdomen, and pelvis as the initial imaging modality for evaluation of vascular access before a TAVR procedure. | 3082594 |
acrac_69419_0 | Acute Trauma to the Knee | Introduction/Background Acute bone and soft-tissue injuries to the knee may result from low- or high-energy trauma and are commonly seen in emergency departments as well as in outpatient practices [1]. The most common acute knee injuries result from a direct blow, a fall, or a twisting injury [2,3]. The fracture risk increases with age, likely secondary to decreased bone mineral density, increased frequency of blunt injury, and inability to protect the knee during a fall [3]. An estimated 6.6 million knee injuries presented to emergency departments in the United States from 1999 through 2008, for a rate of 2.29 knee injuries per 1,000 population. Prompt and accurate diagnosis facilitates adequate management and may prevent potential complications [1,4]. After thorough history and clinical examination, radiographs are usually the initial imaging modality in the evaluation of the acutely injured knee [1]. Adequate clinical examination and appropriate application of the established decision-making rules can reduce the number of radiographic studies in the setting of acute knee injuries with a potential benefit of reducing health care costs and decreasing radiation exposure to the patient [1,5,6]. Treatment options for acute traumatic knee injuries depend on the severity of injury and patient factors and include conservative or surgical management [1]. Special Imaging Considerations For the purpose of this document, point-of-care ultrasound (US) is not discussed or listed in the variant tables. For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [7]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA; however, is 3-D rendering a required element. | Acute Trauma to the Knee. Introduction/Background Acute bone and soft-tissue injuries to the knee may result from low- or high-energy trauma and are commonly seen in emergency departments as well as in outpatient practices [1]. The most common acute knee injuries result from a direct blow, a fall, or a twisting injury [2,3]. The fracture risk increases with age, likely secondary to decreased bone mineral density, increased frequency of blunt injury, and inability to protect the knee during a fall [3]. An estimated 6.6 million knee injuries presented to emergency departments in the United States from 1999 through 2008, for a rate of 2.29 knee injuries per 1,000 population. Prompt and accurate diagnosis facilitates adequate management and may prevent potential complications [1,4]. After thorough history and clinical examination, radiographs are usually the initial imaging modality in the evaluation of the acutely injured knee [1]. Adequate clinical examination and appropriate application of the established decision-making rules can reduce the number of radiographic studies in the setting of acute knee injuries with a potential benefit of reducing health care costs and decreasing radiation exposure to the patient [1,5,6]. Treatment options for acute traumatic knee injuries depend on the severity of injury and patient factors and include conservative or surgical management [1]. Special Imaging Considerations For the purpose of this document, point-of-care ultrasound (US) is not discussed or listed in the variant tables. For the purposes of distinguishing between CT and CT angiography (CTA), ACR Appropriateness Criteria topics use the definition in the ACR-NASCI-SIR-SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA) [7]. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and recons/reformats. Only in CTA; however, is 3-D rendering a required element. | 69419 |
acrac_69419_1 | Acute Trauma to the Knee | 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 society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Acute Trauma to the Knee Discussion of Procedures by Variant Variant 1: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. No focal tenderness, no effusion, able to walk. Initial imaging. CT Knee In the absence of focal tenderness and joint effusion in a patient who is able to walk, CT is not used as the initial imaging study for the evaluation of acute trauma to the knee. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRA Knee MR angiography (MRA) is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Radiography Knee With no clinical symptoms in the injured knee, including lack of focal tenderness and joint effusion, and with ability to walk, knee radiographs may be indicated if a patient >55 years old per Ottawa rules or >50 years old or <12 years old per Pittsburgh rule criteria [5, 6, 10]. If the patient is between 5 and 12 years, they fall outside the age range for both the Ottawa and Pittsburgh rules and radiographs may be beneficial despite lack of clinical symptoms. Radiographs are commonly performed in the setting of acute knee injuries but have a low yield for showing fractures. | Acute Trauma to the Knee. 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 society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] Acute Trauma to the Knee Discussion of Procedures by Variant Variant 1: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. No focal tenderness, no effusion, able to walk. Initial imaging. CT Knee In the absence of focal tenderness and joint effusion in a patient who is able to walk, CT is not used as the initial imaging study for the evaluation of acute trauma to the knee. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRA Knee MR angiography (MRA) is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Radiography Knee With no clinical symptoms in the injured knee, including lack of focal tenderness and joint effusion, and with ability to walk, knee radiographs may be indicated if a patient >55 years old per Ottawa rules or >50 years old or <12 years old per Pittsburgh rule criteria [5, 6, 10]. If the patient is between 5 and 12 years, they fall outside the age range for both the Ottawa and Pittsburgh rules and radiographs may be beneficial despite lack of clinical symptoms. Radiographs are commonly performed in the setting of acute knee injuries but have a low yield for showing fractures. | 69419 |
acrac_69419_2 | Acute Trauma to the Knee | In a retrospective review of 1,967 patients with acute knee injuries by Stiell et al [2], 74.1% of patients had knee radiography, and only 5.2% of these had fractures. Therefore, to avoid a large number of negative radiographic studies, development of the inclusion criteria for obtaining knee radiographs in the setting of the acute trauma was needed. The two most commonly used clinical decision criteria, the Ottawa Knee Rule and the Pittsburgh Decision Rule, can help to decide when to perform radiographs in acute knee trauma [5,6,8]. Pittsburgh Decision Rule The Pittsburgh Decision Rule states that patients with acute knee trauma who are <12 years old or >50 years old should have radiographs as well as patients who cannot take 4 weight-bearing steps in the emergency department [5,6]. In their prospective study in 178 patients with acute knee trauma with the Ottawa rule criteria applied, Jenny et al [8] found a 35% decrease in the number of radiographic examinations with 100% sensitivity for detecting knee fracture. Similarly, Cheung et al [6] found a 23% reduction of knee radiographs in 90 patients if the Ottawa rule criteria were applied, although they did report 1 patient who had a fracture and did not meet any of the clinical criteria, but this fracture was radiographically occult and visible only by MRI. In their retrospective study on 106 acute knee trauma patients, Konan et al [5] evaluated the role of the Ottawa and Pittsburgh rules to reduce the unnecessary use of radiographs following knee injury. One hundred and one patients (95%) had radiographs of their injured knees. Only 5% of these patients had a fracture on radiographs, all with Ottawa and Pittsburgh knee rules fulfilled. Using the Ottawa rules, 27 radiographic studies (25%) could have been Acute Trauma to the Knee avoided without missing a fracture. Using the Pittsburgh rules, 32 radiographic studies (30%) could have been avoided. | Acute Trauma to the Knee. In a retrospective review of 1,967 patients with acute knee injuries by Stiell et al [2], 74.1% of patients had knee radiography, and only 5.2% of these had fractures. Therefore, to avoid a large number of negative radiographic studies, development of the inclusion criteria for obtaining knee radiographs in the setting of the acute trauma was needed. The two most commonly used clinical decision criteria, the Ottawa Knee Rule and the Pittsburgh Decision Rule, can help to decide when to perform radiographs in acute knee trauma [5,6,8]. Pittsburgh Decision Rule The Pittsburgh Decision Rule states that patients with acute knee trauma who are <12 years old or >50 years old should have radiographs as well as patients who cannot take 4 weight-bearing steps in the emergency department [5,6]. In their prospective study in 178 patients with acute knee trauma with the Ottawa rule criteria applied, Jenny et al [8] found a 35% decrease in the number of radiographic examinations with 100% sensitivity for detecting knee fracture. Similarly, Cheung et al [6] found a 23% reduction of knee radiographs in 90 patients if the Ottawa rule criteria were applied, although they did report 1 patient who had a fracture and did not meet any of the clinical criteria, but this fracture was radiographically occult and visible only by MRI. In their retrospective study on 106 acute knee trauma patients, Konan et al [5] evaluated the role of the Ottawa and Pittsburgh rules to reduce the unnecessary use of radiographs following knee injury. One hundred and one patients (95%) had radiographs of their injured knees. Only 5% of these patients had a fracture on radiographs, all with Ottawa and Pittsburgh knee rules fulfilled. Using the Ottawa rules, 27 radiographic studies (25%) could have been Acute Trauma to the Knee avoided without missing a fracture. Using the Pittsburgh rules, 32 radiographic studies (30%) could have been avoided. | 69419 |
acrac_69419_3 | Acute Trauma to the Knee | In this study, both the Ottawa and Pittsburgh rules showed high sensitivity in detecting knee fractures [5]. Other clinical decision criteria were tested. In an emergency department, in a study of 242 patients >17 years with isolated knee injuries sustained 24 hours previously, Weber et al [3] were able to exclude clinically significant fractures in patients >18 years who could walk without limping or if there was a twisting injury to the knee and no joint effusion. These clinical decision rules were effective in detecting knee fractures with 100% sensitivity and with sufficient specificity to eliminate 29% of knee radiographs [3]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with single-photon emission computed tomography (SPECT)/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Variant 2: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. One or more of the following: focal tenderness, effusion, inability to bear weight. Initial imaging. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRA Knee MRA is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Radiography Knee With one or more positive Ottawa rule criteria, including focal tenderness and/or inability to bear weight, radiographs should be the initial imaging modality for the evaluation of acute trauma to the knee [5,6,8]. | Acute Trauma to the Knee. In this study, both the Ottawa and Pittsburgh rules showed high sensitivity in detecting knee fractures [5]. Other clinical decision criteria were tested. In an emergency department, in a study of 242 patients >17 years with isolated knee injuries sustained 24 hours previously, Weber et al [3] were able to exclude clinically significant fractures in patients >18 years who could walk without limping or if there was a twisting injury to the knee and no joint effusion. These clinical decision rules were effective in detecting knee fractures with 100% sensitivity and with sufficient specificity to eliminate 29% of knee radiographs [3]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with single-photon emission computed tomography (SPECT)/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Variant 2: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. One or more of the following: focal tenderness, effusion, inability to bear weight. Initial imaging. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRA Knee MRA is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Radiography Knee With one or more positive Ottawa rule criteria, including focal tenderness and/or inability to bear weight, radiographs should be the initial imaging modality for the evaluation of acute trauma to the knee [5,6,8]. | 69419 |
acrac_69419_4 | Acute Trauma to the Knee | Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Acute Trauma to the Knee Variant 3: Adult or skeletally mature child. Fall or acute twisting trauma to the knee. No fracture seen on radiographs. Suspect occult fracture or internal derangement. Next study. CT Knee CT may be performed as the next imaging study for the evaluation of suspected radiographically occult knee fractures. Several studies reported CT to be superior to knee radiographs in detection and classification of fractures. In a study by Mustonen et al [12], CT showed 100% and radiographs 83% sensitivity in detection of tibial plateau fractures, and CT was superior in further characterization of fracture severity. In the setting of acute knee trauma, Mui et al [13] reported 80% sensitivity and 98% specificity of the CT examination in detecting bony avulsion fractures and a high negative predictive value for excluding ligamentous injuries, but MRI remained necessary for the preoperative detection of meniscal injury. Peltola et al [14] compared dual-energy CT examinations with MRI studies as a reference standard in 18 patients with acute knee trauma and reported dual-energy CT had 79% sensitivity and 100% specificity in detecting anterior cruciate ligament (ACL) ruptures [14]. In a study by Heffernan et al [15], 64-channel multidetector CT showed 87.5% to 100% sensitivity and 100% specificity for detection of the ACL tears. As on MRI, secondary signs, such as buckling of the posterior cruciate ligament, were also useful in their diagnosis. | Acute Trauma to the Knee. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Acute Trauma to the Knee Variant 3: Adult or skeletally mature child. Fall or acute twisting trauma to the knee. No fracture seen on radiographs. Suspect occult fracture or internal derangement. Next study. CT Knee CT may be performed as the next imaging study for the evaluation of suspected radiographically occult knee fractures. Several studies reported CT to be superior to knee radiographs in detection and classification of fractures. In a study by Mustonen et al [12], CT showed 100% and radiographs 83% sensitivity in detection of tibial plateau fractures, and CT was superior in further characterization of fracture severity. In the setting of acute knee trauma, Mui et al [13] reported 80% sensitivity and 98% specificity of the CT examination in detecting bony avulsion fractures and a high negative predictive value for excluding ligamentous injuries, but MRI remained necessary for the preoperative detection of meniscal injury. Peltola et al [14] compared dual-energy CT examinations with MRI studies as a reference standard in 18 patients with acute knee trauma and reported dual-energy CT had 79% sensitivity and 100% specificity in detecting anterior cruciate ligament (ACL) ruptures [14]. In a study by Heffernan et al [15], 64-channel multidetector CT showed 87.5% to 100% sensitivity and 100% specificity for detection of the ACL tears. As on MRI, secondary signs, such as buckling of the posterior cruciate ligament, were also useful in their diagnosis. | 69419 |
acrac_69419_5 | Acute Trauma to the Knee | In this study, multidetector CT showed a low sensitivity for other soft- tissue injuries at the knee; however, its high specificity indicated that apparent posterior cruciate ligament, meniscal, and collateral ligament tears can reliably be treated as true-positive findings [15]. The dual-energy CT virtual noncalcium technique can subtract calcium from cancellous bone, allowing detection [16-18] and possibly grading of the post-traumatic bone marrow contusions [18]. However, MRI is superior to CT in detection of bone marrow abnormalities and meniscal and ligamentous injuries and may be subsequently performed as clinically indicated. MR Arthrography Knee With negative radiographs, MR arthrography is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRA Knee With negative radiographs, MRA is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRI Knee MRI has many distinct advantages for the evaluation of the injured knee in the setting of negative radiographs. The majority of patients (93.5%) who present with acute knee injuries in the emergency department sustained soft- tissue injuries rather than osseous injuries [19]. MRI is a proven valuable tool in the treatment decision-making process, allowing earlier surgical intervention by obtaining a more accurate diagnosis [20,21]. Frobell et al [22] reported a low diagnostic benefit of the initial clinical examination in the setting of acute knee trauma with higher- than-suspected incidence of the ACL injuries on MRI. In randomized studies of patients with knee injuries [23,24], MRI findings shortened the diagnostic completion workup, reduced the number of additional diagnostic procedures, and improved quality of life in the first 6 weeks, potentially reducing productivity loss. | Acute Trauma to the Knee. In this study, multidetector CT showed a low sensitivity for other soft- tissue injuries at the knee; however, its high specificity indicated that apparent posterior cruciate ligament, meniscal, and collateral ligament tears can reliably be treated as true-positive findings [15]. The dual-energy CT virtual noncalcium technique can subtract calcium from cancellous bone, allowing detection [16-18] and possibly grading of the post-traumatic bone marrow contusions [18]. However, MRI is superior to CT in detection of bone marrow abnormalities and meniscal and ligamentous injuries and may be subsequently performed as clinically indicated. MR Arthrography Knee With negative radiographs, MR arthrography is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRA Knee With negative radiographs, MRA is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRI Knee MRI has many distinct advantages for the evaluation of the injured knee in the setting of negative radiographs. The majority of patients (93.5%) who present with acute knee injuries in the emergency department sustained soft- tissue injuries rather than osseous injuries [19]. MRI is a proven valuable tool in the treatment decision-making process, allowing earlier surgical intervention by obtaining a more accurate diagnosis [20,21]. Frobell et al [22] reported a low diagnostic benefit of the initial clinical examination in the setting of acute knee trauma with higher- than-suspected incidence of the ACL injuries on MRI. In randomized studies of patients with knee injuries [23,24], MRI findings shortened the diagnostic completion workup, reduced the number of additional diagnostic procedures, and improved quality of life in the first 6 weeks, potentially reducing productivity loss. | 69419 |
acrac_69419_6 | Acute Trauma to the Knee | A retrospective study by Cecava et al [25] showed that knee radiography is a highly specific screening test for internal derangement in patients <40 years old with acute knee injury. In this patient population, knee effusion >10 mm on lateral radiograph should prompt consideration for the knee MRI examination, which can potentially decrease delayed diagnosis, improve patient outcomes, and decrease disability [25]. Magee et al [26] reported 96% sensitivity and 97% specificity of 3T MRI in the detection of meniscal tears in correlation with arthroscopy. However, a study by Van Dyck et al [21] showed similar high sensitivities and specificities of routine 3T and 1.5T MRI examinations in the evaluation of meniscal and ACL tears with arthroscopic correlation. Routine 3T MRI protocol did not significantly improve accuracy for evaluating the knee menisci and ACL compared with a similar 1.5T MRI protocol. MRI can diagnose the patterns and severity of bone marrow contusions that frequently have an association with the specific mechanisms of injury and can predict associated soft-tissue injuries [27,28]. In a study by Song et al [28], Acute Trauma to the Knee in the setting of the acute noncontact ACL injury, both the presence and the severity of lateral bone contusions were associated with high-grade pivot-shift, concomitant lateral meniscal lesions as well as anterolateral ligament abnormality. Klengel et al [29] found that the apparent diffusion coefficient maps are more sensitive than corresponding proton density-weighted fat-saturated turbo spin-echo MRI sequences for detection of bone marrow lesions after knee trauma and allowed detection of significantly more and larger bone marrow lesions. Additionally, apparent diffusion coefficient map evaluation improved diagnostic performance in regions with insufficient spectral fat saturation, such as the patella. | Acute Trauma to the Knee. A retrospective study by Cecava et al [25] showed that knee radiography is a highly specific screening test for internal derangement in patients <40 years old with acute knee injury. In this patient population, knee effusion >10 mm on lateral radiograph should prompt consideration for the knee MRI examination, which can potentially decrease delayed diagnosis, improve patient outcomes, and decrease disability [25]. Magee et al [26] reported 96% sensitivity and 97% specificity of 3T MRI in the detection of meniscal tears in correlation with arthroscopy. However, a study by Van Dyck et al [21] showed similar high sensitivities and specificities of routine 3T and 1.5T MRI examinations in the evaluation of meniscal and ACL tears with arthroscopic correlation. Routine 3T MRI protocol did not significantly improve accuracy for evaluating the knee menisci and ACL compared with a similar 1.5T MRI protocol. MRI can diagnose the patterns and severity of bone marrow contusions that frequently have an association with the specific mechanisms of injury and can predict associated soft-tissue injuries [27,28]. In a study by Song et al [28], Acute Trauma to the Knee in the setting of the acute noncontact ACL injury, both the presence and the severity of lateral bone contusions were associated with high-grade pivot-shift, concomitant lateral meniscal lesions as well as anterolateral ligament abnormality. Klengel et al [29] found that the apparent diffusion coefficient maps are more sensitive than corresponding proton density-weighted fat-saturated turbo spin-echo MRI sequences for detection of bone marrow lesions after knee trauma and allowed detection of significantly more and larger bone marrow lesions. Additionally, apparent diffusion coefficient map evaluation improved diagnostic performance in regions with insufficient spectral fat saturation, such as the patella. | 69419 |
acrac_69419_7 | Acute Trauma to the Knee | Koster et al [30] showed that the presence of a bone contusion on MRI after acute knee trauma is highly predictive of the development of focal osteoarthritis 1 year after trauma. MRI facilitates diagnosis of the anterolateral ligament injuries that have frequent association with ACL injuries and anterolateral knee instability, of which a minority are associated with Segond fractures [31]. In a study by Kosy et al [32], MRI detected a larger number of anterolateral ligament injuries in association with the ACL injuries within 6 weeks of the acute knee trauma compared with scans performed later, which suggests that some injuries may resolve or become less visible with increased chronicity. MRI is proven helpful in detection and characterization of posterolateral corner injuries, which can be associated with the ACL ruptures and, if missed, may lead to considerable morbidity. In a study by Temponi et al [33], concomitant posterolateral corner injuries and the ACL ruptures were present in 19.7% of patients on MRI studies. Precise location and classification of the ACL tears on the MRI study may help in preoperative planning, in particular with a growing interest in this ligament preservation technique [34]. MRI can change management from surgical to conservative in up to 48% of patients presenting with a locked knee, which is usually an indication for arthroscopic procedure [35,36]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement. Tc-99m-methylene diophosphate bone SPECT/CT scan has been suggested as an alternative to MRI in evaluating suspected bone contusions and meniscal and ACL tears in the setting of acute knee trauma. A SPECT study by Even-Sapir et al [37] with arthroscopic and MRI correlation showed promising results in diagnosis of the ACL and meniscal tears and the associated bone contusions in patients with acute knee trauma. | Acute Trauma to the Knee. Koster et al [30] showed that the presence of a bone contusion on MRI after acute knee trauma is highly predictive of the development of focal osteoarthritis 1 year after trauma. MRI facilitates diagnosis of the anterolateral ligament injuries that have frequent association with ACL injuries and anterolateral knee instability, of which a minority are associated with Segond fractures [31]. In a study by Kosy et al [32], MRI detected a larger number of anterolateral ligament injuries in association with the ACL injuries within 6 weeks of the acute knee trauma compared with scans performed later, which suggests that some injuries may resolve or become less visible with increased chronicity. MRI is proven helpful in detection and characterization of posterolateral corner injuries, which can be associated with the ACL ruptures and, if missed, may lead to considerable morbidity. In a study by Temponi et al [33], concomitant posterolateral corner injuries and the ACL ruptures were present in 19.7% of patients on MRI studies. Precise location and classification of the ACL tears on the MRI study may help in preoperative planning, in particular with a growing interest in this ligament preservation technique [34]. MRI can change management from surgical to conservative in up to 48% of patients presenting with a locked knee, which is usually an indication for arthroscopic procedure [35,36]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement. Tc-99m-methylene diophosphate bone SPECT/CT scan has been suggested as an alternative to MRI in evaluating suspected bone contusions and meniscal and ACL tears in the setting of acute knee trauma. A SPECT study by Even-Sapir et al [37] with arthroscopic and MRI correlation showed promising results in diagnosis of the ACL and meniscal tears and the associated bone contusions in patients with acute knee trauma. | 69419 |
acrac_69419_8 | Acute Trauma to the Knee | Another study by Siegel et al [38] suggested that the degree of radiotracer uptake in the knee, as determined by SPECT, positively correlates with the severity of pathology seen at arthroscopy. However, a more recent SPECT study with arthroscopic correlation by Wertman et al [39] showed a lower sensitivity, specificity, and accuracy than MRI in evaluating meniscal injuries. US Knee US is not used as the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement. US is an excellent and easily performed imaging study in detection of knee joint effusions. However, because of its technical limitations, US may only evaluate the outer bone surface and has a limited role in detection of the occult knee fractures. Therefore, this imaging modality is not routinely used for the evaluation of suspected occult knee fractures but may detect a lipohemarthrosis, which is typically associated with intra-articular fractures. A comparison of US studies with radiography and CT examinations by Bonnefoy et al [40] serving as the reference standard and using a knee lipohemarthrosis as a criterion, yielded a sensitivity of and specificity of 94% for US detection of acute intra-articular fractures. A recent study by Klos et al [41] showed a higher prevalence of Segond avulsions fractures on US studies than previously reported in literature on the MRI or radiography. The lateral femoral condyle impaction injury was the best variable in predicting the presence of a Segond fracture [41]. Acute Trauma to the Knee US study by Dai et al including 551 patients from 7 prospective studies revealed pooled sensitivity of 88% and specificity of 90% in diagnosis of meniscal injuries [46]. Variant 4: Skeletally immature child. Fall or acute twisting trauma to the knee. No fracture seen on radiographs. Suspect occult fracture or internal derangement. Next study. | Acute Trauma to the Knee. Another study by Siegel et al [38] suggested that the degree of radiotracer uptake in the knee, as determined by SPECT, positively correlates with the severity of pathology seen at arthroscopy. However, a more recent SPECT study with arthroscopic correlation by Wertman et al [39] showed a lower sensitivity, specificity, and accuracy than MRI in evaluating meniscal injuries. US Knee US is not used as the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement. US is an excellent and easily performed imaging study in detection of knee joint effusions. However, because of its technical limitations, US may only evaluate the outer bone surface and has a limited role in detection of the occult knee fractures. Therefore, this imaging modality is not routinely used for the evaluation of suspected occult knee fractures but may detect a lipohemarthrosis, which is typically associated with intra-articular fractures. A comparison of US studies with radiography and CT examinations by Bonnefoy et al [40] serving as the reference standard and using a knee lipohemarthrosis as a criterion, yielded a sensitivity of and specificity of 94% for US detection of acute intra-articular fractures. A recent study by Klos et al [41] showed a higher prevalence of Segond avulsions fractures on US studies than previously reported in literature on the MRI or radiography. The lateral femoral condyle impaction injury was the best variable in predicting the presence of a Segond fracture [41]. Acute Trauma to the Knee US study by Dai et al including 551 patients from 7 prospective studies revealed pooled sensitivity of 88% and specificity of 90% in diagnosis of meniscal injuries [46]. Variant 4: Skeletally immature child. Fall or acute twisting trauma to the knee. No fracture seen on radiographs. Suspect occult fracture or internal derangement. Next study. | 69419 |
acrac_69419_9 | Acute Trauma to the Knee | CT Knee With negative radiographs, CT may be performed as the next imaging study for the evaluation of suspected radiographically occult knee fractures [12] and bone marrow contusions [16-18]. CT may diagnose or predict ligamentous injuries [14,15,50,51] and predict meniscal [15,50,51] injuries. However, MRI is superior to CT in evaluation of bone marrow lesions [27-29], meniscal [21,26] and ligamentous [21,31-34] injuries, and may be subsequently performed as clinically indicated. MR Arthrography Knee With negative radiographs, MR arthrography is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRA Knee With negative radiographs, MRA is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRI Knee MRI should be the next imaging modality to evaluate for the presence of radiographically occult fractures and/or internal derangements of the acutely injured knee. With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31-34]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement. Even-Sapir et al [37] showed promising results of a SPECT study in diagnosis of the ACL and meniscal tears and the associated bone contusions in patients with acute knee trauma with arthroscopic and MRI correlation. However, a more recent SPECT study with arthroscopic correlation by Wertman et al [39] showed a lower sensitivity, specificity, and accuracy than MRI in evaluating meniscal injuries. | Acute Trauma to the Knee. CT Knee With negative radiographs, CT may be performed as the next imaging study for the evaluation of suspected radiographically occult knee fractures [12] and bone marrow contusions [16-18]. CT may diagnose or predict ligamentous injuries [14,15,50,51] and predict meniscal [15,50,51] injuries. However, MRI is superior to CT in evaluation of bone marrow lesions [27-29], meniscal [21,26] and ligamentous [21,31-34] injuries, and may be subsequently performed as clinically indicated. MR Arthrography Knee With negative radiographs, MR arthrography is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRA Knee With negative radiographs, MRA is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement. MRI Knee MRI should be the next imaging modality to evaluate for the presence of radiographically occult fractures and/or internal derangements of the acutely injured knee. With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31-34]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement. Even-Sapir et al [37] showed promising results of a SPECT study in diagnosis of the ACL and meniscal tears and the associated bone contusions in patients with acute knee trauma with arthroscopic and MRI correlation. However, a more recent SPECT study with arthroscopic correlation by Wertman et al [39] showed a lower sensitivity, specificity, and accuracy than MRI in evaluating meniscal injuries. | 69419 |
acrac_69419_10 | Acute Trauma to the Knee | US Knee US would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement of the acutely injured knee. However, US may demonstrate a lipohemarthrosis, indicating the presence of an intra-articular fracture [40]. US is an excellent imaging modality for the diagnosis of quadriceps tendon tears [42] with good performance in the evaluation of the meniscal [44-46] and ligamentous [47-49] injuries. However, the utility of US in the evaluation of the knee menisci, cruciate and collateral ligaments, and periarticular soft tissues varies depending on patient factors. Variant 5: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. Tibial plateau fracture on radiographs. Suspect additional bone or soft-tissue injury. Next study. CT Knee In patients with radiographic diagnosis of the tibial plateau fracture, CT is frequently performed for further classification and characterization of the fracture severity [12,52] and may predict or diagnose ligamentous injuries [13-15,50,51] and predict meniscal injuries [15,50]. A study by Spiro et al [50] found that the amount of articular surface depression on CT is a predictor of meniscal and ligamentous injuries and can suggest when an MRI is indicated to confirm or exclude meniscal and ligamentous injuries [50]. In a study by Mustonen et al [12], CT showed 100% sensitivity and radiographs 83% sensitivity in detection of tibial plateau fractures, and CT was superior in further characterization of fracture severity. Chang et al [52] reported that CT-reconstructed images Acute Trauma to the Knee enhance the morphological subclassification of the medial tibial plateau fractures (Schatzker type IV) with common involvement of posterolateral quadrants. In the setting of acute knee trauma, Mui et al [13] reported 80% sensitivity and 98% specificity of the CT examination in detecting bony avulsion fractures. | Acute Trauma to the Knee. US Knee US would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement of the acutely injured knee. However, US may demonstrate a lipohemarthrosis, indicating the presence of an intra-articular fracture [40]. US is an excellent imaging modality for the diagnosis of quadriceps tendon tears [42] with good performance in the evaluation of the meniscal [44-46] and ligamentous [47-49] injuries. However, the utility of US in the evaluation of the knee menisci, cruciate and collateral ligaments, and periarticular soft tissues varies depending on patient factors. Variant 5: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. Tibial plateau fracture on radiographs. Suspect additional bone or soft-tissue injury. Next study. CT Knee In patients with radiographic diagnosis of the tibial plateau fracture, CT is frequently performed for further classification and characterization of the fracture severity [12,52] and may predict or diagnose ligamentous injuries [13-15,50,51] and predict meniscal injuries [15,50]. A study by Spiro et al [50] found that the amount of articular surface depression on CT is a predictor of meniscal and ligamentous injuries and can suggest when an MRI is indicated to confirm or exclude meniscal and ligamentous injuries [50]. In a study by Mustonen et al [12], CT showed 100% sensitivity and radiographs 83% sensitivity in detection of tibial plateau fractures, and CT was superior in further characterization of fracture severity. Chang et al [52] reported that CT-reconstructed images Acute Trauma to the Knee enhance the morphological subclassification of the medial tibial plateau fractures (Schatzker type IV) with common involvement of posterolateral quadrants. In the setting of acute knee trauma, Mui et al [13] reported 80% sensitivity and 98% specificity of the CT examination in detecting bony avulsion fractures. | 69419 |
acrac_69419_11 | Acute Trauma to the Knee | Tang et al [51] found that lateral tibial plateau depression of >11 mm and its specific part involvement on preoperative CT scans could help predict a higher risk of the lateral meniscus tear and the ACL avulsion fracture. MR Arthrography Knee With a radiographic diagnosis of tibial plateau fracture, MR arthrography of the knee is not performed to evaluate for additional bone or soft-tissue injury. MRA Knee With a radiographic diagnosis of tibial plateau fracture, MRA of the knee is not performed to evaluate for additional bone or soft-tissue injury. MRI Knee With a radiographic diagnosis of tibial plateau fracture, MRI would be the next best imaging modality to evaluate for the presence of additional radiographically occult fractures and/or internal derangements of the acutely injured knee. With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31-34]. Bone Scan with SPECT or SPECT/CT Knee With a radiographic diagnosis of tibial plateau fracture, Tc-99m bone scan with SPECT/CT is not performed as the next best imaging study to evaluate for additional bone or soft-tissue injury. US Knee With a radiographic diagnosis of tibial plateau fracture, US is not performed as the next best imaging study to evaluate for additional bone or soft-tissue injury. Variant 6: Adult or child 5 years of age or older. Acute trauma to the knee. Mechanism unknown. Focal patellar tenderness, effusion, able to walk. Initial Imaging. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee but is superior to knee radiographs in detection and classification of fractures [12]. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. | Acute Trauma to the Knee. Tang et al [51] found that lateral tibial plateau depression of >11 mm and its specific part involvement on preoperative CT scans could help predict a higher risk of the lateral meniscus tear and the ACL avulsion fracture. MR Arthrography Knee With a radiographic diagnosis of tibial plateau fracture, MR arthrography of the knee is not performed to evaluate for additional bone or soft-tissue injury. MRA Knee With a radiographic diagnosis of tibial plateau fracture, MRA of the knee is not performed to evaluate for additional bone or soft-tissue injury. MRI Knee With a radiographic diagnosis of tibial plateau fracture, MRI would be the next best imaging modality to evaluate for the presence of additional radiographically occult fractures and/or internal derangements of the acutely injured knee. With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31-34]. Bone Scan with SPECT or SPECT/CT Knee With a radiographic diagnosis of tibial plateau fracture, Tc-99m bone scan with SPECT/CT is not performed as the next best imaging study to evaluate for additional bone or soft-tissue injury. US Knee With a radiographic diagnosis of tibial plateau fracture, US is not performed as the next best imaging study to evaluate for additional bone or soft-tissue injury. Variant 6: Adult or child 5 years of age or older. Acute trauma to the knee. Mechanism unknown. Focal patellar tenderness, effusion, able to walk. Initial Imaging. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee but is superior to knee radiographs in detection and classification of fractures [12]. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. | 69419 |
acrac_69419_12 | Acute Trauma to the Knee | MRA Knee MRA is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI aids in diagnosis and further characterization of bone and soft-tissue injuries associated with transient lateral dislocation of the patella [53-55]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Acute Trauma to the Knee Variant 7: Adult or child 5 years of age or older. Significant trauma to the knee (eg, motor vehicle accident, knee dislocation). Initial imaging. Arteriography Lower Extremity Vascular injury may be found in about 30% of patients following posterior knee dislocation [56]. Injuries of the popliteal artery require prompt surgical intervention to help limb preservation. Associated peroneal and tibial nerve injuries may cause significant morbidity and require an understanding of their pathophysiologic implications to maximize limb functionality [57]. Angiography has been the reference standard in the evaluation of vascular injuries associated with knee dislocations [58]. However, this is an invasive procedure with associated risk, and with the excellent performance of CTA and MRA, it is usually performed in selected cases [58]. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. CT is superior to knee radiographs in detection and classification of fractures [12]; however, without IV contrast, CT cannot detect vascular injuries. CTA Lower Extremity With suspected vascular injuries in the setting of knee dislocation, CTA is frequently used because it is less invasive and has a similarly high accuracy as conventional angiography [58-60]. | Acute Trauma to the Knee. MRA Knee MRA is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI aids in diagnosis and further characterization of bone and soft-tissue injuries associated with transient lateral dislocation of the patella [53-55]. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. Acute Trauma to the Knee Variant 7: Adult or child 5 years of age or older. Significant trauma to the knee (eg, motor vehicle accident, knee dislocation). Initial imaging. Arteriography Lower Extremity Vascular injury may be found in about 30% of patients following posterior knee dislocation [56]. Injuries of the popliteal artery require prompt surgical intervention to help limb preservation. Associated peroneal and tibial nerve injuries may cause significant morbidity and require an understanding of their pathophysiologic implications to maximize limb functionality [57]. Angiography has been the reference standard in the evaluation of vascular injuries associated with knee dislocations [58]. However, this is an invasive procedure with associated risk, and with the excellent performance of CTA and MRA, it is usually performed in selected cases [58]. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. CT is superior to knee radiographs in detection and classification of fractures [12]; however, without IV contrast, CT cannot detect vascular injuries. CTA Lower Extremity With suspected vascular injuries in the setting of knee dislocation, CTA is frequently used because it is less invasive and has a similarly high accuracy as conventional angiography [58-60]. | 69419 |
acrac_69419_13 | Acute Trauma to the Knee | MR Arthrography Knee In patients with significant acute knee trauma with suspected or possible dislocation, MR arthrography of the knee is not routinely used as the initial imaging study. MRA Knee MRI is an accurate method used in the evaluation of soft-tissue, osseous, and neural injuries after knee dislocation [61]. MRA may be performed simultaneously with MRI for evaluation of internal derangement and vascular injuries with less morbidity compared with conventional angiography [62]. Potter et al [61] reported their experience with popliteal fossa MRA with encouraging results and complete agreement between the MRA and conventional angiography in patients who had both studies. Similarly, in a study by Tocci et al [62], MRA has been shown to be as accurate and useful as conventional angiography in the evaluation of popliteal artery injuries of patients with knee dislocations. MRI Knee With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31,32]. It can be performed in conjunction with MRA for evaluation of internal derangement and vascular injuries with less morbidity compared with conventional angiography [62]. Bone Scan with SPECT or SPECT/CT Knee In patients with significant acute knee trauma with suspected/possible dislocation, Tc-99m bone scan with SPECT/CT is not routinely used as the initial imaging study. US Knee In patients with significant acute knee trauma with suspected or possible dislocation, US is not routinely used as the initial imaging study. 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. | Acute Trauma to the Knee. MR Arthrography Knee In patients with significant acute knee trauma with suspected or possible dislocation, MR arthrography of the knee is not routinely used as the initial imaging study. MRA Knee MRI is an accurate method used in the evaluation of soft-tissue, osseous, and neural injuries after knee dislocation [61]. MRA may be performed simultaneously with MRI for evaluation of internal derangement and vascular injuries with less morbidity compared with conventional angiography [62]. Potter et al [61] reported their experience with popliteal fossa MRA with encouraging results and complete agreement between the MRA and conventional angiography in patients who had both studies. Similarly, in a study by Tocci et al [62], MRA has been shown to be as accurate and useful as conventional angiography in the evaluation of popliteal artery injuries of patients with knee dislocations. MRI Knee With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31,32]. It can be performed in conjunction with MRA for evaluation of internal derangement and vascular injuries with less morbidity compared with conventional angiography [62]. Bone Scan with SPECT or SPECT/CT Knee In patients with significant acute knee trauma with suspected/possible dislocation, Tc-99m bone scan with SPECT/CT is not routinely used as the initial imaging study. US Knee In patients with significant acute knee trauma with suspected or possible dislocation, US is not routinely used as the initial imaging study. 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. | 69419 |
acrac_69357_0 | Right Lower Quadrant Pain | Introduction/Background Right lower quadrant (RLQ) abdominal pain accounts for nearly 50% of patients presenting to the emergency department with abdominal pain [1]. Appendicitis is the most common surgical pathology responsible for RLQ abdominal pain in the United States [1,2]. Other less frequent causes of RLQ pain include right colonic diverticulitis, ureteral stone, colitis, and intestinal obstruction [1,3,4]. Imaging remains the diagnostic mainstay in the workup of patients presenting with RLQ abdominal pain for evaluation of suspected appendicitis and diagnosis of other conditions. Buckius et al [2] reported an annual increase in the rate of acute appendicitis in the United States; however, Ferris et al [5], in a recent systematic review of population-based studies, showed that although the incidence of both perforated and nonperforated appendicitis is stable in North America, the incidence is rising in newly industrialized countries. Historically, the clinical determination of appendicitis has been poor, particularly in special patient populations, such as those at the extremes of age and pregnant women. The negative appendectomy rate (NAR) based on clinical determination alone without imaging is unacceptably high, as high as 25% [6]. Clinical decisions tools, such as the Alvarado score (AS), have not improved the outright diagnostic accuracy of the clinical examination [7] and demonstrate mixed results as an adjunct to help guide CT use [8,9]. The decrease in NAR with increased imaging utilization is not accompanied by an increase in perforations from any introduced delays [10,11]. The choice of imaging modality should be tailored for diagnosis of acute appendicitis in patients with a high degree of suspicion but should also allow diagnosis of other causes of RLQ pain to triage appropriate patient management. | Right Lower Quadrant Pain. Introduction/Background Right lower quadrant (RLQ) abdominal pain accounts for nearly 50% of patients presenting to the emergency department with abdominal pain [1]. Appendicitis is the most common surgical pathology responsible for RLQ abdominal pain in the United States [1,2]. Other less frequent causes of RLQ pain include right colonic diverticulitis, ureteral stone, colitis, and intestinal obstruction [1,3,4]. Imaging remains the diagnostic mainstay in the workup of patients presenting with RLQ abdominal pain for evaluation of suspected appendicitis and diagnosis of other conditions. Buckius et al [2] reported an annual increase in the rate of acute appendicitis in the United States; however, Ferris et al [5], in a recent systematic review of population-based studies, showed that although the incidence of both perforated and nonperforated appendicitis is stable in North America, the incidence is rising in newly industrialized countries. Historically, the clinical determination of appendicitis has been poor, particularly in special patient populations, such as those at the extremes of age and pregnant women. The negative appendectomy rate (NAR) based on clinical determination alone without imaging is unacceptably high, as high as 25% [6]. Clinical decisions tools, such as the Alvarado score (AS), have not improved the outright diagnostic accuracy of the clinical examination [7] and demonstrate mixed results as an adjunct to help guide CT use [8,9]. The decrease in NAR with increased imaging utilization is not accompanied by an increase in perforations from any introduced delays [10,11]. The choice of imaging modality should be tailored for diagnosis of acute appendicitis in patients with a high degree of suspicion but should also allow diagnosis of other causes of RLQ pain to triage appropriate patient management. | 69357 |
acrac_69425_0 | Chronic Hip Pain PCAs | Introduction/Background Chronic hip pain is a common chief complaint for patients, reportedly affecting 30% to 40% of adults who play sports [1,2], and 12% to 15% of all adults over 60 [3,4]. A wide variety of pathological entities may cause hip pain, including osseous as well as intra- or extra-articular soft tissue abnormalities [5-7]. Pathology involving the lumbar spine, sacroiliac, or knee joints can also cause hip pain [8], and these etiologies should be investigated as needed. There is limited original research that specifically targets the imaging of chronic hip pain, but imaging of specific conditions is widely discussed in the published literature. OR The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Hip Pain Discussion of Procedures by Variant Variant 1: Chronic hip pain. Initial Imaging. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the initial evaluation of chronic hip pain. CT Arthrography Hip There is no relevant literature to support the use of CT arthrography of the hip in the initial evaluation of chronic hip pain. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with intravenous (IV) contrast in the initial evaluation of chronic hip pain. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast in the initial evaluation of chronic hip pain. CT Hip Without IV Contrast There is no relevant literature to support the use of CT of the hip without IV contrast in the initial evaluation of chronic hip pain. | Chronic Hip Pain PCAs. Introduction/Background Chronic hip pain is a common chief complaint for patients, reportedly affecting 30% to 40% of adults who play sports [1,2], and 12% to 15% of all adults over 60 [3,4]. A wide variety of pathological entities may cause hip pain, including osseous as well as intra- or extra-articular soft tissue abnormalities [5-7]. Pathology involving the lumbar spine, sacroiliac, or knee joints can also cause hip pain [8], and these etiologies should be investigated as needed. There is limited original research that specifically targets the imaging of chronic hip pain, but imaging of specific conditions is widely discussed in the published literature. OR The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: [email protected] Chronic Hip Pain Discussion of Procedures by Variant Variant 1: Chronic hip pain. Initial Imaging. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the initial evaluation of chronic hip pain. CT Arthrography Hip There is no relevant literature to support the use of CT arthrography of the hip in the initial evaluation of chronic hip pain. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with intravenous (IV) contrast in the initial evaluation of chronic hip pain. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast in the initial evaluation of chronic hip pain. CT Hip Without IV Contrast There is no relevant literature to support the use of CT of the hip without IV contrast in the initial evaluation of chronic hip pain. | 69425 |
acrac_69425_1 | Chronic Hip Pain PCAs | Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the initial evaluation of chronic hip pain. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures There is no relevant literature to support the use of image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures in the initial evaluation of chronic hip pain. MR Arthrography Hip There is no relevant literature to support the use of MR arthrography of the hip in the initial evaluation of chronic hip pain. MRI Hip Without and With IV Contrast There is no relevant literature to support the use of MRI of the hip without and with IV contrast in the initial evaluation of chronic hip pain. MRI Hip Without IV Contrast There is no relevant literature to support the use of MRI of the hip without IV contrast in the initial evaluation of chronic hip pain. Radiography Hip The literature indicates that radiography is a first-line screening tool, and hip radiographs are useful in the initial imaging workup of chronic hip pain [12]. Oftentimes a pelvic radiograph, which includes imaging of both hips, may be obtained concurrently with additional dedicated collimated radiograph(s) of the affected hip(s). Findings on hip radiographs can result in an imaging diagnosis such as osteoarthritis or can lead to more advanced workups of less common causes of chronic hip pain such as primary bone tumors. The results of screening hip radiographs can help guide the use of additional imaging studies such as more specialized radiographic views or more advanced modalities such as CT, ultrasound (US), MRI, radionuclide bone scans, and fluoride PET [13-15]. Radiography Pelvis The literature indicates that radiography is a first-line screening tool, and pelvic radiographs are useful in the initial imaging workup of chronic hip pain [12]. | Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the initial evaluation of chronic hip pain. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures There is no relevant literature to support the use of image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures in the initial evaluation of chronic hip pain. MR Arthrography Hip There is no relevant literature to support the use of MR arthrography of the hip in the initial evaluation of chronic hip pain. MRI Hip Without and With IV Contrast There is no relevant literature to support the use of MRI of the hip without and with IV contrast in the initial evaluation of chronic hip pain. MRI Hip Without IV Contrast There is no relevant literature to support the use of MRI of the hip without IV contrast in the initial evaluation of chronic hip pain. Radiography Hip The literature indicates that radiography is a first-line screening tool, and hip radiographs are useful in the initial imaging workup of chronic hip pain [12]. Oftentimes a pelvic radiograph, which includes imaging of both hips, may be obtained concurrently with additional dedicated collimated radiograph(s) of the affected hip(s). Findings on hip radiographs can result in an imaging diagnosis such as osteoarthritis or can lead to more advanced workups of less common causes of chronic hip pain such as primary bone tumors. The results of screening hip radiographs can help guide the use of additional imaging studies such as more specialized radiographic views or more advanced modalities such as CT, ultrasound (US), MRI, radionuclide bone scans, and fluoride PET [13-15]. Radiography Pelvis The literature indicates that radiography is a first-line screening tool, and pelvic radiographs are useful in the initial imaging workup of chronic hip pain [12]. | 69425 |
acrac_69425_2 | Chronic Hip Pain PCAs | A pelvic radiograph is an excellent initial examination because it allows for evaluation of both hip joints on a single radiographic image, allowing for comparison of the ipsilateral and contralateral hips. Oftentimes, a pelvic radiograph may be obtained concurrently with additional dedicated radiograph(s) of the affected hip. Findings on pelvic radiographs can result in an imaging diagnosis such as osteoarthritis or may lead to more advanced workups of less common causes of chronic hip pain such as primary bone tumors. The results of the pelvic radiograph can help the clinician for the selection of additional imaging techniques and for comparison with studies such as MRI, CT, radionuclide bone scans, and fluoride PET [13-15]. Chronic Hip Pain US Hip There is no relevant literature to support the use of US hip in the initial evaluation of chronic hip pain. Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the evaluation of extra-articular soft tissue abnormalities. CT Arthrography Hip The instillation of intra-articular contrast may elucidate periarticular soft tissue abnormalities such as labral or capsular pathology [16-18]. However, CT arthrography is limited for evaluating the extra-articular soft tissue pathology because of the inherent poor soft tissue contrast of CT. Within the limitation of CT; however, some extra- articular pathologic entities, such as a large, distended bursa may be evident on CT. Tendinous pathology is not particularly well depicted on CT. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast in the evaluation of tendon or bursal pathology. | Chronic Hip Pain PCAs. A pelvic radiograph is an excellent initial examination because it allows for evaluation of both hip joints on a single radiographic image, allowing for comparison of the ipsilateral and contralateral hips. Oftentimes, a pelvic radiograph may be obtained concurrently with additional dedicated radiograph(s) of the affected hip. Findings on pelvic radiographs can result in an imaging diagnosis such as osteoarthritis or may lead to more advanced workups of less common causes of chronic hip pain such as primary bone tumors. The results of the pelvic radiograph can help the clinician for the selection of additional imaging techniques and for comparison with studies such as MRI, CT, radionuclide bone scans, and fluoride PET [13-15]. Chronic Hip Pain US Hip There is no relevant literature to support the use of US hip in the initial evaluation of chronic hip pain. Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the evaluation of extra-articular soft tissue abnormalities. CT Arthrography Hip The instillation of intra-articular contrast may elucidate periarticular soft tissue abnormalities such as labral or capsular pathology [16-18]. However, CT arthrography is limited for evaluating the extra-articular soft tissue pathology because of the inherent poor soft tissue contrast of CT. Within the limitation of CT; however, some extra- articular pathologic entities, such as a large, distended bursa may be evident on CT. Tendinous pathology is not particularly well depicted on CT. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast in the evaluation of tendon or bursal pathology. | 69425 |
acrac_69425_3 | Chronic Hip Pain PCAs | CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast in the evaluation of tendon or bursal pathology. CT Hip Without IV Contrast CT hip without IV contrast is of limited use in the evaluation of extra-articular soft tissue pathology because of the inherent poor soft tissue contrast of CT [18]. Within the limitation of the contrast resolution of CT, some extra- articular pathologic entities, such as a large, distended bursa may be evident on CT. Tendinous pathology is not well evaluated on CT. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to a noninfectious extra-articular abnormality. MR Arthrography Hip There is no relevant literature to support the use of MR arthrography in the evaluation of extra-articular soft tissue pathology. MRI Hip Without and With IV Contrast There is no relevant literature to support administration of IV contrast (gadolinium chelate agents) for routine MRI of the hip. MRI Hip Without IV Contrast MRI without IV contrast is useful for evaluating soft tissues given its high soft tissue contrast resolution [23]. Numerous studies have demonstrated that MRI is both highly sensitive and specific for evaluation of the articular and periarticular soft tissues [24]. As such, noncontrast MRI should be considered as the next imaging test following radiographic evaluation of the hip joint [25-34]. Trochanteric, iliopsoas, ischial, and subiliacus bursitis are well demonstrated on noncontrast MRI, as are abductor and adductor tendinosis and tears, hamstring injuries, athletic pubalgia, and calcific tendinosis. Large field-of-view images obtained as part of a hip MRI can also sometimes Chronic Hip Pain US Hip The literature indicates that US is useful for the evaluation of extra-articular soft tissues in the region of the hip [23]. | Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast in the evaluation of tendon or bursal pathology. CT Hip Without IV Contrast CT hip without IV contrast is of limited use in the evaluation of extra-articular soft tissue pathology because of the inherent poor soft tissue contrast of CT [18]. Within the limitation of the contrast resolution of CT, some extra- articular pathologic entities, such as a large, distended bursa may be evident on CT. Tendinous pathology is not well evaluated on CT. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to a noninfectious extra-articular abnormality. MR Arthrography Hip There is no relevant literature to support the use of MR arthrography in the evaluation of extra-articular soft tissue pathology. MRI Hip Without and With IV Contrast There is no relevant literature to support administration of IV contrast (gadolinium chelate agents) for routine MRI of the hip. MRI Hip Without IV Contrast MRI without IV contrast is useful for evaluating soft tissues given its high soft tissue contrast resolution [23]. Numerous studies have demonstrated that MRI is both highly sensitive and specific for evaluation of the articular and periarticular soft tissues [24]. As such, noncontrast MRI should be considered as the next imaging test following radiographic evaluation of the hip joint [25-34]. Trochanteric, iliopsoas, ischial, and subiliacus bursitis are well demonstrated on noncontrast MRI, as are abductor and adductor tendinosis and tears, hamstring injuries, athletic pubalgia, and calcific tendinosis. Large field-of-view images obtained as part of a hip MRI can also sometimes Chronic Hip Pain US Hip The literature indicates that US is useful for the evaluation of extra-articular soft tissues in the region of the hip [23]. | 69425 |
acrac_69425_4 | Chronic Hip Pain PCAs | US can also nicely demonstrate fluid collections around the hip, such as bursitis and paralabral cysts. Tendon pathology, such as tendinosis, tears, or snapping iliopsoas tendons can also be identified with US [38-41]. US may also be useful for the dynamic evaluation of the iliopsoas tendon, such as in snapping hip syndrome. Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support to the use of bone scan of the hip in the evaluation of suspected hip impingement. CT Arthrography Hip Pathology associated with femoracetabular impingement (FAI) may be both intra- and extra-articular. CT is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. CT arthrography has been shown to be sensitive for detection of acetabular labral tears [17], which may be associated with FAI. CT arthrography has also been shown to be more helpful in identifying chondral lesions [16] when compared to MRI. However, arthrography does not offer an advantage over noncontrast CT for the detection of extra-articular impingement (eg, ischiopelvic, ischiotrochanteric, subspinous, and femoropelvic). CT Hip With IV Contrast CT without IV contrast is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. However, IV contrast administration does not confer an additional advantage for evaluation of hip impingement. CT Hip Without and With IV Contrast Noncontrast CT is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. IV contrast administration is not warranted for evaluation of hip impingement. Fluoride PET/CT Skull Base to Mid-Thigh One study demonstrated the potential use of fluoride PET to demonstrate increased bone turnover in the setting of chronic hip pain and FAI [50]. | Chronic Hip Pain PCAs. US can also nicely demonstrate fluid collections around the hip, such as bursitis and paralabral cysts. Tendon pathology, such as tendinosis, tears, or snapping iliopsoas tendons can also be identified with US [38-41]. US may also be useful for the dynamic evaluation of the iliopsoas tendon, such as in snapping hip syndrome. Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support to the use of bone scan of the hip in the evaluation of suspected hip impingement. CT Arthrography Hip Pathology associated with femoracetabular impingement (FAI) may be both intra- and extra-articular. CT is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. CT arthrography has been shown to be sensitive for detection of acetabular labral tears [17], which may be associated with FAI. CT arthrography has also been shown to be more helpful in identifying chondral lesions [16] when compared to MRI. However, arthrography does not offer an advantage over noncontrast CT for the detection of extra-articular impingement (eg, ischiopelvic, ischiotrochanteric, subspinous, and femoropelvic). CT Hip With IV Contrast CT without IV contrast is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. However, IV contrast administration does not confer an additional advantage for evaluation of hip impingement. CT Hip Without and With IV Contrast Noncontrast CT is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. IV contrast administration is not warranted for evaluation of hip impingement. Fluoride PET/CT Skull Base to Mid-Thigh One study demonstrated the potential use of fluoride PET to demonstrate increased bone turnover in the setting of chronic hip pain and FAI [50]. | 69425 |
acrac_69425_5 | Chronic Hip Pain PCAs | One other study demonstrated that fluoride PET can demonstrate acetabular contrecoup injuries in patients with FAI [51]. However, increased radiotracer uptake is a nonspecific finding, and, overall, there is insufficient literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to hip impingement and/or dysplasia. Chronic Hip Pain MR Arthrography Hip Direct MR arthrography, performed following the intra-articular injection of a 1:200 solution of gadolinium chelate in saline, is useful for diagnosing acetabular labral tears [65-70] that are frequently associated with FAI [71,72] and/or hip dysplasia. MR arthrography has been shown to have a sensitivity of 94.5% and a specificity of 100% for the detection of labral tears [52], which may be associated with FAI. Some authors have shown that MRI without IV contrast and MR arthrography are similarly accurate and sensitive for detecting labral tears in the setting of FAI [53], and other authors have shown that MR arthrography is superior to conventional MRI [54,55]. Several publications show that MR arthrography is superior to CT arthrography and noncontrast MRI for evaluation of labral tears [18,56], but there are other publications that demonstrate that CT arthrography and noncontrast MRI are superior [16,57-59]. MR arthrography may also nicely demonstrate acetabular chondral delamination [60]. Although MR arthrography can be useful for demonstrating labral and chondral pathology associated with impingement, the presence of intra-articular contrast offers no advantage over noncontrast MRI for the detection of extra-articular abnormalities associated with impingement. MRI Hip Without and With IV Contrast Indirect arthrography is a technique that falls under the category of MRI hip with contrast. When administered intravenously, gadolinium chelate contrast can diffuse into the joint space via the synovium, and this results in indirect arthrography. | Chronic Hip Pain PCAs. One other study demonstrated that fluoride PET can demonstrate acetabular contrecoup injuries in patients with FAI [51]. However, increased radiotracer uptake is a nonspecific finding, and, overall, there is insufficient literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to hip impingement and/or dysplasia. Chronic Hip Pain MR Arthrography Hip Direct MR arthrography, performed following the intra-articular injection of a 1:200 solution of gadolinium chelate in saline, is useful for diagnosing acetabular labral tears [65-70] that are frequently associated with FAI [71,72] and/or hip dysplasia. MR arthrography has been shown to have a sensitivity of 94.5% and a specificity of 100% for the detection of labral tears [52], which may be associated with FAI. Some authors have shown that MRI without IV contrast and MR arthrography are similarly accurate and sensitive for detecting labral tears in the setting of FAI [53], and other authors have shown that MR arthrography is superior to conventional MRI [54,55]. Several publications show that MR arthrography is superior to CT arthrography and noncontrast MRI for evaluation of labral tears [18,56], but there are other publications that demonstrate that CT arthrography and noncontrast MRI are superior [16,57-59]. MR arthrography may also nicely demonstrate acetabular chondral delamination [60]. Although MR arthrography can be useful for demonstrating labral and chondral pathology associated with impingement, the presence of intra-articular contrast offers no advantage over noncontrast MRI for the detection of extra-articular abnormalities associated with impingement. MRI Hip Without and With IV Contrast Indirect arthrography is a technique that falls under the category of MRI hip with contrast. When administered intravenously, gadolinium chelate contrast can diffuse into the joint space via the synovium, and this results in indirect arthrography. | 69425 |
acrac_69425_6 | Chronic Hip Pain PCAs | There is limited literature supporting the use of indirect arthrography instead of direct MR arthrography for evaluating intra-articular disorders [34,61-63]. IV, rather than intra-articular, injection of contrast is faster and easier to perform and does not require image guidance, but indirect arthrography does not distend the joint capsule and results in less consistent enhancement of the joint space. The accuracy of indirect arthrography for evaluation of the acetabular labrum and articular cartilage remains uncertain. Because the literature supporting indirect arthrography is scant, it is a technique that is not often used clinically. MRI without IV contrast is useful for evaluating the labrum and articular cartilage in the setting of FAI and/or dysplasia. It can even be used for the detailed assessment of osseous anatomy, such as the shape and contour of the femoral neck. A noncontrast MRI can demonstrate findings of extra-articular impingement as well. At times, indirect arthrography may be performed following noncontrast image acquisition in order to obtain a complementary assessment of the hip and its synovium. MRI Hip Without IV Contrast FAI and dysplasia are associated with both intra- and extra-articular abnormalities, both osseous and soft tissue. The literature demonstrates that a noncontrast MRI is useful in the assessment of labral and cartilage lesions in the setting of hip impingement. Investigators have demonstrated success in detecting labral and articular cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast [58,68]. Additional literature has shown that high-resolution 3T MRI without IV contrast can further improve the visualization of the acetabular labrum and the articular cartilage of the femoral head and acetabulum [69,70]. Evaluation of cortical bone is more difficult with conventional MRI than it is with CT, but the use of isotropic MR sequences has been shown to be effective in the evaluation of FAI [71]. | Chronic Hip Pain PCAs. There is limited literature supporting the use of indirect arthrography instead of direct MR arthrography for evaluating intra-articular disorders [34,61-63]. IV, rather than intra-articular, injection of contrast is faster and easier to perform and does not require image guidance, but indirect arthrography does not distend the joint capsule and results in less consistent enhancement of the joint space. The accuracy of indirect arthrography for evaluation of the acetabular labrum and articular cartilage remains uncertain. Because the literature supporting indirect arthrography is scant, it is a technique that is not often used clinically. MRI without IV contrast is useful for evaluating the labrum and articular cartilage in the setting of FAI and/or dysplasia. It can even be used for the detailed assessment of osseous anatomy, such as the shape and contour of the femoral neck. A noncontrast MRI can demonstrate findings of extra-articular impingement as well. At times, indirect arthrography may be performed following noncontrast image acquisition in order to obtain a complementary assessment of the hip and its synovium. MRI Hip Without IV Contrast FAI and dysplasia are associated with both intra- and extra-articular abnormalities, both osseous and soft tissue. The literature demonstrates that a noncontrast MRI is useful in the assessment of labral and cartilage lesions in the setting of hip impingement. Investigators have demonstrated success in detecting labral and articular cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast [58,68]. Additional literature has shown that high-resolution 3T MRI without IV contrast can further improve the visualization of the acetabular labrum and the articular cartilage of the femoral head and acetabulum [69,70]. Evaluation of cortical bone is more difficult with conventional MRI than it is with CT, but the use of isotropic MR sequences has been shown to be effective in the evaluation of FAI [71]. | 69425 |
acrac_69425_7 | Chronic Hip Pain PCAs | Some centers routinely evaluate the shape and contours of the femoral neck by utilizing radial imaging or radial reconstructions. Additional research has shown that the zero-echo time pulse sequence offers excellent visualization of cortical bone on MRI without the need for contrast, and it has been shown to be an effective sequence for evaluating osseous hip morphology [72]. MRI can also be useful in detecting extra-articular impingements (ischiopelvic, ischiotrochanteric, subspinous, and femoropelvic) [45,46]. Although there is a paucity of supportive data, some surgeons may use both MRI and CT in order to define the soft tissues (labrum and articular cartilage) and the bone, respectively. Measurements can be performed on radiography, CT, and MRI [42-44,47,48]. Chronic Hip Pain Radiography Hip Additional Views For further evaluation of disorders such as dysplasia or FAI, specialized views such as the false profile or elongated femoral neck lateral (Dunn) views can provide more detailed evaluation of the anatomy of the femoral head and neck and the degree of acetabular coverage of the femoral head [47]. US Hip In general, US is limited in its use for evaluating osseous structures. However, there is limited literature that demonstrates that US can be used to evaluate osseous features of FAI such as the alpha-angle [73]. However, US is not able to adequately evaluate osseous abnormalities deep to the cortex. One of the advantages of US is its ability to dynamically evaluate for extra-articular soft tissue impingement. US is not as sensitive as MRI or CT arthrography for the detection of labral tears [17], but it can be useful for the detection and localization of paralabral cysts for aspiration and injection [39,41]. Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip for the workup of an acetabular labral tear in a patient with chronic hip pain. | Chronic Hip Pain PCAs. Some centers routinely evaluate the shape and contours of the femoral neck by utilizing radial imaging or radial reconstructions. Additional research has shown that the zero-echo time pulse sequence offers excellent visualization of cortical bone on MRI without the need for contrast, and it has been shown to be an effective sequence for evaluating osseous hip morphology [72]. MRI can also be useful in detecting extra-articular impingements (ischiopelvic, ischiotrochanteric, subspinous, and femoropelvic) [45,46]. Although there is a paucity of supportive data, some surgeons may use both MRI and CT in order to define the soft tissues (labrum and articular cartilage) and the bone, respectively. Measurements can be performed on radiography, CT, and MRI [42-44,47,48]. Chronic Hip Pain Radiography Hip Additional Views For further evaluation of disorders such as dysplasia or FAI, specialized views such as the false profile or elongated femoral neck lateral (Dunn) views can provide more detailed evaluation of the anatomy of the femoral head and neck and the degree of acetabular coverage of the femoral head [47]. US Hip In general, US is limited in its use for evaluating osseous structures. However, there is limited literature that demonstrates that US can be used to evaluate osseous features of FAI such as the alpha-angle [73]. However, US is not able to adequately evaluate osseous abnormalities deep to the cortex. One of the advantages of US is its ability to dynamically evaluate for extra-articular soft tissue impingement. US is not as sensitive as MRI or CT arthrography for the detection of labral tears [17], but it can be useful for the detection and localization of paralabral cysts for aspiration and injection [39,41]. Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip for the workup of an acetabular labral tear in a patient with chronic hip pain. | 69425 |
acrac_69425_8 | Chronic Hip Pain PCAs | CT Arthrography Hip Some authors have shown that CT arthrography can be useful in the detection of acetabular labral tears [17,74], which may be associated with FAI, but other authors have shown that CT arthrography is not very good for the detection of labral tears [18]. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain. CT Hip Without IV Contrast Because of its inherent poor contrast resolution, there is no relevant literature supporting the use of CT hip without IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to a labral tear. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures Diagnostic joint injections are safe and useful tools for confirming the etiology of pain, such as a labral tear or symptomatic paralabral cyst [20-22]. MR Arthrography Hip Direct MR arthrography, with the intraarticular injection of a 1:200 solution of gadolinium chelate in saline, has been established as a reliable technique for diagnosing acetabular labral tears [75-80] that are frequently associated with FAI [81,82]. MR arthrography has been shown to have a sensitivity of 94.5% and a specificity of 100% for the detection of labral tears [52]. Within some of the published literature, MR arthrography has often been demonstrated to be superior to CT arthrography and noncontrast MRI for evaluation of labral tears [18,56]. However, in other articles, CT arthrography and noncontrast MRI fare better [16,57-59]. | Chronic Hip Pain PCAs. CT Arthrography Hip Some authors have shown that CT arthrography can be useful in the detection of acetabular labral tears [17,74], which may be associated with FAI, but other authors have shown that CT arthrography is not very good for the detection of labral tears [18]. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain. CT Hip Without IV Contrast Because of its inherent poor contrast resolution, there is no relevant literature supporting the use of CT hip without IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to a labral tear. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures Diagnostic joint injections are safe and useful tools for confirming the etiology of pain, such as a labral tear or symptomatic paralabral cyst [20-22]. MR Arthrography Hip Direct MR arthrography, with the intraarticular injection of a 1:200 solution of gadolinium chelate in saline, has been established as a reliable technique for diagnosing acetabular labral tears [75-80] that are frequently associated with FAI [81,82]. MR arthrography has been shown to have a sensitivity of 94.5% and a specificity of 100% for the detection of labral tears [52]. Within some of the published literature, MR arthrography has often been demonstrated to be superior to CT arthrography and noncontrast MRI for evaluation of labral tears [18,56]. However, in other articles, CT arthrography and noncontrast MRI fare better [16,57-59]. | 69425 |
acrac_69425_9 | Chronic Hip Pain PCAs | MRI Hip Without and With IV Contrast Indirect arthrography is a technique that falls under the category of MRI hip with contrast. For performance of indirect MR arthrography, gadolinium chelate contrast is administered by IV injection and diffuses into the joint space through the synovium. This technique has been proposed as an alternative to direct MR arthrography for detecting intra-articular disorders [34,61-63] because it is faster and easier to perform than direct arthrography and does not require image guidance. However, indirect arthrography offers less consistent enhancement of the joint space and cannot distend the joint capsule. Although the literature is scant, there are a few small studies suggesting Chronic Hip Pain that indirect MR arthrography may be helpful in detecting labral pathology [83,84]. However, as the literature supporting indirect arthrography is very limited, it is a technique that is not often used clinically. MRI Hip Without IV Contrast MRI is currently the reference standard for evaluation of labral pathology [85]. For evaluating labral tears, MRI with or without arthrography can be used [76-79]. Several investigators suggest that high-resolution 3T MRI may improve the visualization of the acetabular labrum and the hyaline articular cartilage [69,70], which may obviate the need for intra-articular contrast [86]. Other investigators have obtained satisfactory results in detecting labral and hyaline cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast [58,68]. US Hip Although not as commonly used as MRI for the detection of labral pathology, US has been able to document the presence of labral tears in patients with hip pain [87,88]. However, it is not as sensitive as other modalities for detecting labral tears [17]. US can also be used to localize paralabral cysts for aspiration and injection [39,41]. Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. | Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast Indirect arthrography is a technique that falls under the category of MRI hip with contrast. For performance of indirect MR arthrography, gadolinium chelate contrast is administered by IV injection and diffuses into the joint space through the synovium. This technique has been proposed as an alternative to direct MR arthrography for detecting intra-articular disorders [34,61-63] because it is faster and easier to perform than direct arthrography and does not require image guidance. However, indirect arthrography offers less consistent enhancement of the joint space and cannot distend the joint capsule. Although the literature is scant, there are a few small studies suggesting Chronic Hip Pain that indirect MR arthrography may be helpful in detecting labral pathology [83,84]. However, as the literature supporting indirect arthrography is very limited, it is a technique that is not often used clinically. MRI Hip Without IV Contrast MRI is currently the reference standard for evaluation of labral pathology [85]. For evaluating labral tears, MRI with or without arthrography can be used [76-79]. Several investigators suggest that high-resolution 3T MRI may improve the visualization of the acetabular labrum and the hyaline articular cartilage [69,70], which may obviate the need for intra-articular contrast [86]. Other investigators have obtained satisfactory results in detecting labral and hyaline cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast [58,68]. US Hip Although not as commonly used as MRI for the detection of labral pathology, US has been able to document the presence of labral tears in patients with hip pain [87,88]. However, it is not as sensitive as other modalities for detecting labral tears [17]. US can also be used to localize paralabral cysts for aspiration and injection [39,41]. Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. | 69425 |
acrac_69425_10 | Chronic Hip Pain PCAs | Evaluate articular cartilage integrity. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the assessment of the extent of cartilage damage in a patient with chronic hip pain. CT Arthrography Hip Direct visualization of articular cartilage is possible using those imaging techniques that provide either intrinsic contrast (MRI and US) or extrinsic contrast (any type of arthrography) [89]. Hip cartilage abnormalities can be successfully evaluated by high-resolution CT arthrography [18,90-93], thus allowing for improved assessment of the degree of cartilage loss when compared with the initial radiographs. CT Hip With IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip with IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain. CT Hip Without and With IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip without and with IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain. CT Hip Without IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip without IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the assessment of the extent of cartilage damage in a patient with chronic hip pain. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures Although image-guided anesthetic and/or corticosteroid injections may be useful in the diagnosis and treatment of patients with osteoarthritis, it does not offer the possibility of evaluating the extent of cartilage damage that may exist in a joint. | Chronic Hip Pain PCAs. Evaluate articular cartilage integrity. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the assessment of the extent of cartilage damage in a patient with chronic hip pain. CT Arthrography Hip Direct visualization of articular cartilage is possible using those imaging techniques that provide either intrinsic contrast (MRI and US) or extrinsic contrast (any type of arthrography) [89]. Hip cartilage abnormalities can be successfully evaluated by high-resolution CT arthrography [18,90-93], thus allowing for improved assessment of the degree of cartilage loss when compared with the initial radiographs. CT Hip With IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip with IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain. CT Hip Without and With IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip without and with IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain. CT Hip Without IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip without IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the assessment of the extent of cartilage damage in a patient with chronic hip pain. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures Although image-guided anesthetic and/or corticosteroid injections may be useful in the diagnosis and treatment of patients with osteoarthritis, it does not offer the possibility of evaluating the extent of cartilage damage that may exist in a joint. | 69425 |
acrac_69425_11 | Chronic Hip Pain PCAs | Image-guided therapeutic injections have not been shown to alter patient reported outcome measures [94]. MR Arthrography Hip Direct visualization of articular cartilage is possible on MRI because of its intrinsic excellent soft tissue contrast resolution. Intra-articular administration of contrast can also help with the direct visualization of articular cartilage [89]. MR arthrography has been shown to have high sensitivity and fair specificity of 92.5% and 54.5%, respectively, for the detection of chondral pathology in the setting of FAI [52]. A lower sensitivity for the detection of chondral pathology has been reported for the detection of hip articular cartilage defects in a more generalized group of patients [55]. Assessment of the T2* relaxation time is not affected by the presence of intra-articular gadolinium injection [95], and, although more commonly used for research purposes, T2* may be used to assess cartilage ultrastructure. Chronic Hip Pain MRI Hip Without and With IV Contrast Indirect arthrography falls under the technique of MRI hip with IV contrast. The diagnostic accuracy of indirect MR arthrography has not been widely studied [96], and, as such, there is insufficient literature to support the use of MRI with IV contrast in assessment for the degree of cartilage damage. IV contrast administration can; however, help to demonstrate the degree of enhancing inflamed synovium. Delayed gadolinium-enhanced MRI of cartilage may be useful in assessing the degree of hip cartilage damage, but this is most frequently employed in the research setting [97]. Overall, given the scant literature supporting indirect arthrography, this is a technique that is not often used clinically. MRI Hip Without IV Contrast Direct visualization of articular cartilage is possible on MRI because of its intrinsic excellent soft tissue contrast resolution [89]. MRI can demonstrate the articular cartilage and areas of chondral pathology [18,91,93]. | Chronic Hip Pain PCAs. Image-guided therapeutic injections have not been shown to alter patient reported outcome measures [94]. MR Arthrography Hip Direct visualization of articular cartilage is possible on MRI because of its intrinsic excellent soft tissue contrast resolution. Intra-articular administration of contrast can also help with the direct visualization of articular cartilage [89]. MR arthrography has been shown to have high sensitivity and fair specificity of 92.5% and 54.5%, respectively, for the detection of chondral pathology in the setting of FAI [52]. A lower sensitivity for the detection of chondral pathology has been reported for the detection of hip articular cartilage defects in a more generalized group of patients [55]. Assessment of the T2* relaxation time is not affected by the presence of intra-articular gadolinium injection [95], and, although more commonly used for research purposes, T2* may be used to assess cartilage ultrastructure. Chronic Hip Pain MRI Hip Without and With IV Contrast Indirect arthrography falls under the technique of MRI hip with IV contrast. The diagnostic accuracy of indirect MR arthrography has not been widely studied [96], and, as such, there is insufficient literature to support the use of MRI with IV contrast in assessment for the degree of cartilage damage. IV contrast administration can; however, help to demonstrate the degree of enhancing inflamed synovium. Delayed gadolinium-enhanced MRI of cartilage may be useful in assessing the degree of hip cartilage damage, but this is most frequently employed in the research setting [97]. Overall, given the scant literature supporting indirect arthrography, this is a technique that is not often used clinically. MRI Hip Without IV Contrast Direct visualization of articular cartilage is possible on MRI because of its intrinsic excellent soft tissue contrast resolution [89]. MRI can demonstrate the articular cartilage and areas of chondral pathology [18,91,93]. | 69425 |
acrac_69425_12 | Chronic Hip Pain PCAs | MRI has been shown to be 85.92% accurate for identification of acetabular chondral rim lesions when compared to arthroscopy [85]. Various MRI techniques such as T2 mapping, T1rho, and sodium imaging allow for the ultrastructural assessment of articular cartilage [98]. Although these techniques are primarily used in the research setting, some have also been applied in the routine evaluation of clinical patients. US Hip US is limited in the hip by its inability to evaluate the acetabular or the majority of the femoral head cartilage. The acoustic window to see articular cartilage in the hip is limited. Variant 6: Chronic hip pain. Radiographs suspicious for intra-articular synovial hyperplasia or neoplasia including nodular synovitis, diffuse tenosynovial giant cell tumor, osteochondromatosis, other synovial neoplasm. Next imaging study. Image-Guided Aspiration Hip Image-guided aspiration/injections demonstrate brown or bloody aspirate in patients with the diffuse form of tenosynovial giant cell tumor [99,100]. The diagnosis of synovial hyperplasia/neoplasia may require a tissue sample. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. CT Arthrography Hip CT arthrography may be helpful in evaluating whether there are intra-articular bodies or hypertrophic synovium. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast for the workup of synovial hyperplasia/neoplasia in a patient with chronic hip pain. CT Hip Without and With IV Contrast It can be quite difficult to distinguish diffuse tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes on imaging. CT without IV contrast might help to detect calcification. However, there is no added benefit of administering IV contrast for the diagnosis of a synovial proliferative process. | Chronic Hip Pain PCAs. MRI has been shown to be 85.92% accurate for identification of acetabular chondral rim lesions when compared to arthroscopy [85]. Various MRI techniques such as T2 mapping, T1rho, and sodium imaging allow for the ultrastructural assessment of articular cartilage [98]. Although these techniques are primarily used in the research setting, some have also been applied in the routine evaluation of clinical patients. US Hip US is limited in the hip by its inability to evaluate the acetabular or the majority of the femoral head cartilage. The acoustic window to see articular cartilage in the hip is limited. Variant 6: Chronic hip pain. Radiographs suspicious for intra-articular synovial hyperplasia or neoplasia including nodular synovitis, diffuse tenosynovial giant cell tumor, osteochondromatosis, other synovial neoplasm. Next imaging study. Image-Guided Aspiration Hip Image-guided aspiration/injections demonstrate brown or bloody aspirate in patients with the diffuse form of tenosynovial giant cell tumor [99,100]. The diagnosis of synovial hyperplasia/neoplasia may require a tissue sample. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. CT Arthrography Hip CT arthrography may be helpful in evaluating whether there are intra-articular bodies or hypertrophic synovium. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast for the workup of synovial hyperplasia/neoplasia in a patient with chronic hip pain. CT Hip Without and With IV Contrast It can be quite difficult to distinguish diffuse tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes on imaging. CT without IV contrast might help to detect calcification. However, there is no added benefit of administering IV contrast for the diagnosis of a synovial proliferative process. | 69425 |
acrac_69425_13 | Chronic Hip Pain PCAs | CT Hip Without IV Contrast Intra-articular sources of pain such as synovitis, whether inflammatory (eg, Lyme disease), proliferative (eg, synovial chondromatosis), or neoplastic (eg, chondroma), are well demonstrated on MRI. It can be quite difficult to distinguish tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes, although CT might help to detect subtle calcifications, which can sometimes be seen with synovial chondromatosis but are not typically seen in the setting of tenosynovial giant cell tumor. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures There is no relevant literature to support the use of image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. Chronic Hip Pain MR Arthrography Hip Instillation of intra-articular contrast may be helpful in elucidating whether a body/bodies are intra-articular. However, in cases in which precise intra-articular pathology is still unknown and neoplasm remains a consideration, histologic sampling of the neoplastic process is probably indicated before instillation of contrast into the joint to avoid unintended harm. MRI Hip Without and With IV Contrast MRI hip with IV contrast administration may be helpful in distinguishing enhancing inflamed synovium from a bland joint effusion. MRI Hip Without IV Contrast Intra-articular sources of pain such as synovitis, whether inflammatory (eg, Lyme disease), proliferative (eg, synovial chondromatosis), or neoplastic (eg, chondroma), are well demonstrated on MRI. | Chronic Hip Pain PCAs. CT Hip Without IV Contrast Intra-articular sources of pain such as synovitis, whether inflammatory (eg, Lyme disease), proliferative (eg, synovial chondromatosis), or neoplastic (eg, chondroma), are well demonstrated on MRI. It can be quite difficult to distinguish tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes, although CT might help to detect subtle calcifications, which can sometimes be seen with synovial chondromatosis but are not typically seen in the setting of tenosynovial giant cell tumor. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures There is no relevant literature to support the use of image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. Chronic Hip Pain MR Arthrography Hip Instillation of intra-articular contrast may be helpful in elucidating whether a body/bodies are intra-articular. However, in cases in which precise intra-articular pathology is still unknown and neoplasm remains a consideration, histologic sampling of the neoplastic process is probably indicated before instillation of contrast into the joint to avoid unintended harm. MRI Hip Without and With IV Contrast MRI hip with IV contrast administration may be helpful in distinguishing enhancing inflamed synovium from a bland joint effusion. MRI Hip Without IV Contrast Intra-articular sources of pain such as synovitis, whether inflammatory (eg, Lyme disease), proliferative (eg, synovial chondromatosis), or neoplastic (eg, chondroma), are well demonstrated on MRI. | 69425 |
acrac_69425_14 | Chronic Hip Pain PCAs | It can be quite difficult to distinguish tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes. MRI, including a gradient-echo sequence, may be useful in assessing for blooming, which would indicate the presence of hemosiderin, such as can be seen in tenosynovial giant cell tumor. US Hip There is no relevant literature to support the use of diagnostic US hip in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. Variant 7: Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study. Bone Scan Hip Although a bone scan of the hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. CT Hip With IV Contrast Although CT hip with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. CT Hip Without and With IV Contrast Although CT hip without and with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. CT Hip Without IV Contrast Although CT hip without IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. Fluoride PET/CT Skull Base to Mid-Thigh Although fluoride PET/CT skull base to mid-thigh may be able to demonstrate pathology about the hip, knee, and spine, it cannot be used to quantify the amount pain that is generated from the hip pathology. MR Arthrography Hip Although MR arthrography hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. If anesthetic is mixed with the contrast that is injected Chronic Hip Pain | Chronic Hip Pain PCAs. It can be quite difficult to distinguish tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes. MRI, including a gradient-echo sequence, may be useful in assessing for blooming, which would indicate the presence of hemosiderin, such as can be seen in tenosynovial giant cell tumor. US Hip There is no relevant literature to support the use of diagnostic US hip in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain. Variant 7: Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study. Bone Scan Hip Although a bone scan of the hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. CT Hip With IV Contrast Although CT hip with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. CT Hip Without and With IV Contrast Although CT hip without and with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. CT Hip Without IV Contrast Although CT hip without IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. Fluoride PET/CT Skull Base to Mid-Thigh Although fluoride PET/CT skull base to mid-thigh may be able to demonstrate pathology about the hip, knee, and spine, it cannot be used to quantify the amount pain that is generated from the hip pathology. MR Arthrography Hip Although MR arthrography hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. If anesthetic is mixed with the contrast that is injected Chronic Hip Pain | 69425 |
acrac_3158172_0 | Ataxia Child | Specific manifestations of ataxia may correspond to certain causes or may be discovered by particular triggers. For example, truncal ataxia is typical of cerebellar vermian pathology [1]. A lurching gait, when triggered by head rotation, is typical of vestibular dysfunction [9]. Sensory ataxia can be revealed by a positive Romberg test, which examines the dorsal columns. [9]. Additionally, ataxia with specific signs can suggest the underlying disorder. Pupillary abnormalities may suggest drug or toxin ingestion versus third cranial nerve compression. Torticollis or resistance to head and neck motion may indicate pathology at the craniocervical junction, cord compression, or posterior fossa tumor [9]. Based on a systematic review of European data, the estimated prevalence of childhood ataxia due to genetic and acquired causes is approximately 26 per 100,000 children, although the true worldwide prevalence may be higher [10]. Regional variations exist in the prevalence of childhood ataxia, with a higher prevalence of genetic causes of ataxia in countries with high consanguinity, and a higher prevalence of infectious causes such as malaria and varicella in other regions where these diseases are more common [10]. Evaluation of ataxia requires careful review of demographics, history (especially duration of symptoms and the presence of additional neurological deficits), clinical examination, laboratory testing, and neuroimaging to reach a cohesive diagnosis [2,7,11-13]. In young children and infants, a detailed neurological examination is often challenging, and initial imaging therefore plays a critical role in arriving at a diagnosis. The time course of illness (eg, acute, recurrent, chronic with or without progression) may indicate or rule out potential etiology. Acute onset ataxia typically refers to ataxia that develops within hours or days and frequently presents within 72 hours, whereas chronic ataxia is defined as ataxia lasting longer than 2 months [1,14]. | Ataxia Child. Specific manifestations of ataxia may correspond to certain causes or may be discovered by particular triggers. For example, truncal ataxia is typical of cerebellar vermian pathology [1]. A lurching gait, when triggered by head rotation, is typical of vestibular dysfunction [9]. Sensory ataxia can be revealed by a positive Romberg test, which examines the dorsal columns. [9]. Additionally, ataxia with specific signs can suggest the underlying disorder. Pupillary abnormalities may suggest drug or toxin ingestion versus third cranial nerve compression. Torticollis or resistance to head and neck motion may indicate pathology at the craniocervical junction, cord compression, or posterior fossa tumor [9]. Based on a systematic review of European data, the estimated prevalence of childhood ataxia due to genetic and acquired causes is approximately 26 per 100,000 children, although the true worldwide prevalence may be higher [10]. Regional variations exist in the prevalence of childhood ataxia, with a higher prevalence of genetic causes of ataxia in countries with high consanguinity, and a higher prevalence of infectious causes such as malaria and varicella in other regions where these diseases are more common [10]. Evaluation of ataxia requires careful review of demographics, history (especially duration of symptoms and the presence of additional neurological deficits), clinical examination, laboratory testing, and neuroimaging to reach a cohesive diagnosis [2,7,11-13]. In young children and infants, a detailed neurological examination is often challenging, and initial imaging therefore plays a critical role in arriving at a diagnosis. The time course of illness (eg, acute, recurrent, chronic with or without progression) may indicate or rule out potential etiology. Acute onset ataxia typically refers to ataxia that develops within hours or days and frequently presents within 72 hours, whereas chronic ataxia is defined as ataxia lasting longer than 2 months [1,14]. | 3158172 |
acrac_3158172_1 | Ataxia Child | Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Whereas nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, progressive childhood ataxia may be due to inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. Reprint requests to: [email protected] Although MIBG (iodine-123 meta-iodobenzylguanidine) and CT imaging of the chest, abdomen, and pelvis is used in specific workup of children presenting with opsoclonus-myoclonus-ataxia syndrome, for diagnosing underlying neuroblastoma or ganglioneuroblastoma, they may not typically be the first line of imaging. It should be noted that opsoclonus-myoclonus-ataxia syndrome is one of the less common presentations of tumors such as neuroblastoma or ganglioneuroblastoma. A complete description of signs and symptoms of neuroblastoma or ganglioneuroblastoma and their workup are beyond the scope of this document. Ataxia-Child Cerebellar stroke is a rare cause of acute ataxia in children, with one series identifying 3 cases out of 364 children presenting to the emergency department with acute ataxia [26]. Despite its rarity, diagnosing acute cerebellar infarct is critical because of implications for appropriate diagnostic workup and management. Collective assessment of several studies suggests that, although acute imaging may reveal a clinically urgent condition [1,7,21,22,25-27], the yield of clinically significant findings may be highest in children >3 years of age with symptoms for >3 days duration and in the presence of extracerebellar symptoms, such as somnolence, encephalopathy, focal motor weakness, or cranial nerve involvement [13,18,20,26]. | Ataxia Child. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Whereas nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, progressive childhood ataxia may be due to inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction. Reprint requests to: [email protected] Although MIBG (iodine-123 meta-iodobenzylguanidine) and CT imaging of the chest, abdomen, and pelvis is used in specific workup of children presenting with opsoclonus-myoclonus-ataxia syndrome, for diagnosing underlying neuroblastoma or ganglioneuroblastoma, they may not typically be the first line of imaging. It should be noted that opsoclonus-myoclonus-ataxia syndrome is one of the less common presentations of tumors such as neuroblastoma or ganglioneuroblastoma. A complete description of signs and symptoms of neuroblastoma or ganglioneuroblastoma and their workup are beyond the scope of this document. Ataxia-Child Cerebellar stroke is a rare cause of acute ataxia in children, with one series identifying 3 cases out of 364 children presenting to the emergency department with acute ataxia [26]. Despite its rarity, diagnosing acute cerebellar infarct is critical because of implications for appropriate diagnostic workup and management. Collective assessment of several studies suggests that, although acute imaging may reveal a clinically urgent condition [1,7,21,22,25-27], the yield of clinically significant findings may be highest in children >3 years of age with symptoms for >3 days duration and in the presence of extracerebellar symptoms, such as somnolence, encephalopathy, focal motor weakness, or cranial nerve involvement [13,18,20,26]. | 3158172 |
acrac_3158172_2 | Ataxia Child | In young children presenting with acute cerebellar ataxia and a recent history of viral illness but without extracerebellar neurologic signs and symptoms and a negative urine drug screen, watchful waiting has been suggested [18], with imaging reserved for those with clinical deterioration. Therefore, the need for neuroimaging in the acute setting should be guided by the clinical presentation, history, and laboratory testing. CT Head In a large study assessing imaging in 104 children presenting with acute or subacute ataxia, CT abnormalities were identified in up to 29% of children [20]. Clinically significant findings have been identified on CT in 7% of children presenting with acute ataxia [18]. Although the study by Whelan et al [13] only showed significant intracranial abnormalities on CT in 2.5% of the children presenting with acute ataxia, their study was limited by the fact that only a small proportion of children had imaging. In the absence of preceding trauma, CT is useful in identifying nontraumatic acute intracranial hemorrhage but can also identify hydrocephalus, cerebellar edema, and calcifications [7,28]. However, CT is less sensitive than MRI in displaying intracranial pathology including posterior fossa abnormalities [20,26]. There is no relevant literature to support the use of contrast-enhanced head CT in the evaluation of acute childhood ataxia. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with acute ataxia and no history of recent trauma. CTA Head and Neck CT angiography (CTA) of the head and neck may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. | Ataxia Child. In young children presenting with acute cerebellar ataxia and a recent history of viral illness but without extracerebellar neurologic signs and symptoms and a negative urine drug screen, watchful waiting has been suggested [18], with imaging reserved for those with clinical deterioration. Therefore, the need for neuroimaging in the acute setting should be guided by the clinical presentation, history, and laboratory testing. CT Head In a large study assessing imaging in 104 children presenting with acute or subacute ataxia, CT abnormalities were identified in up to 29% of children [20]. Clinically significant findings have been identified on CT in 7% of children presenting with acute ataxia [18]. Although the study by Whelan et al [13] only showed significant intracranial abnormalities on CT in 2.5% of the children presenting with acute ataxia, their study was limited by the fact that only a small proportion of children had imaging. In the absence of preceding trauma, CT is useful in identifying nontraumatic acute intracranial hemorrhage but can also identify hydrocephalus, cerebellar edema, and calcifications [7,28]. However, CT is less sensitive than MRI in displaying intracranial pathology including posterior fossa abnormalities [20,26]. There is no relevant literature to support the use of contrast-enhanced head CT in the evaluation of acute childhood ataxia. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with acute ataxia and no history of recent trauma. CTA Head and Neck CT angiography (CTA) of the head and neck may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. | 3158172 |
acrac_3158172_3 | Ataxia Child | Although there is no relevant literature distinguishing between CTA of head and neck versus CTA of either the head or neck alone in these rare vascular causes of acute childhood ataxia, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone because the site of vascular abnormality may be in either the head or the neck or both locations. Ataxia-Child CTA Head CTA of the head in conjunction with CTA of the neck may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or a vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. CTA Neck CTA of the neck, in conjunction with CTA of the head, may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or a vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. CTV Head There is no relevant literature to support the use of CT venography (CTV) head in the initial evaluation of a child with acute ataxia and no history of recent trauma. MRI Head In a study of 104 children imaged for acute or subacute ataxia, MRI abnormalities were identified in 64% of the cases [20]. However, clinically significant intracranial abnormalities on MRI have been reported in 14% of children presenting with acute or subacute ataxia [18,20]. MRI is more sensitive than CT in the evaluation of intracranial pathology in acute ataxia in children [20]. In a study by Luetje at al [20], abnormalities were identified on MRI but not on CT in 8 children. | Ataxia Child. Although there is no relevant literature distinguishing between CTA of head and neck versus CTA of either the head or neck alone in these rare vascular causes of acute childhood ataxia, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone because the site of vascular abnormality may be in either the head or the neck or both locations. Ataxia-Child CTA Head CTA of the head in conjunction with CTA of the neck may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or a vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. CTA Neck CTA of the neck, in conjunction with CTA of the head, may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or a vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. CTV Head There is no relevant literature to support the use of CT venography (CTV) head in the initial evaluation of a child with acute ataxia and no history of recent trauma. MRI Head In a study of 104 children imaged for acute or subacute ataxia, MRI abnormalities were identified in 64% of the cases [20]. However, clinically significant intracranial abnormalities on MRI have been reported in 14% of children presenting with acute or subacute ataxia [18,20]. MRI is more sensitive than CT in the evaluation of intracranial pathology in acute ataxia in children [20]. In a study by Luetje at al [20], abnormalities were identified on MRI but not on CT in 8 children. | 3158172 |
acrac_3158172_4 | Ataxia Child | Intravenous (IV) contrast is helpful in infectious and postinfectious disorders, demyelinating conditions, and brain tumors, which are the common causes of acute cerebellar ataxia in children [19]. MRI Complete Spine MRI of the spine may be helpful in children with ataxia due to causes such as acute disseminated encephalomyelitis, brain tumors, and demyelinating disease, all of which may show additional abnormalities of the spinal cord [29]. Generally, if there is a high clinical suspicion for a condition that may have spinal cord or paravertebral abnormalities, MRI of the spine can be included when imaging the neuroaxis. Although there is no relevant literature discussing the specific use of contrast in MRI of the spine in acute childhood ataxia, addition of postcontrast imaging may be useful in assessing neoplastic, demyelinating, and inflammatory lesions, which are common causes of acute cerebellar ataxia in children [20]. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with acute ataxia and no history of recent trauma. MRA Head and Neck MR angiography (MRA) of the head and neck may be a helpful tool in assessing ataxia due to a posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. Although there is no relevant literature distinguishing between MRA of head and neck versus MRA of either the head or MRA neck alone in these rare vascular causes of acute childhood ataxia, MRA of the head and neck may be more beneficial than either MRA head or neck alone because the site of vascular abnormality may be in either the head or neck or both locations. | Ataxia Child. Intravenous (IV) contrast is helpful in infectious and postinfectious disorders, demyelinating conditions, and brain tumors, which are the common causes of acute cerebellar ataxia in children [19]. MRI Complete Spine MRI of the spine may be helpful in children with ataxia due to causes such as acute disseminated encephalomyelitis, brain tumors, and demyelinating disease, all of which may show additional abnormalities of the spinal cord [29]. Generally, if there is a high clinical suspicion for a condition that may have spinal cord or paravertebral abnormalities, MRI of the spine can be included when imaging the neuroaxis. Although there is no relevant literature discussing the specific use of contrast in MRI of the spine in acute childhood ataxia, addition of postcontrast imaging may be useful in assessing neoplastic, demyelinating, and inflammatory lesions, which are common causes of acute cerebellar ataxia in children [20]. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with acute ataxia and no history of recent trauma. MRA Head and Neck MR angiography (MRA) of the head and neck may be a helpful tool in assessing ataxia due to a posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. Although there is no relevant literature distinguishing between MRA of head and neck versus MRA of either the head or MRA neck alone in these rare vascular causes of acute childhood ataxia, MRA of the head and neck may be more beneficial than either MRA head or neck alone because the site of vascular abnormality may be in either the head or neck or both locations. | 3158172 |
acrac_3158172_5 | Ataxia Child | MRA Head MRA of the head in conjunction with MRA of the neck may be a helpful tool in assessing ataxia due to posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. MRA Neck MRA of the neck in conjunction with MRA of the head may be a helpful tool in assessing ataxia due to posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. Ataxia-Child MRV Head and Neck There is no relevant literature to support the use of MR venography (MRV) head and neck in the initial evaluation of a child with acute ataxia and no history of recent trauma. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with acute ataxia and no history of recent trauma. MIBG Scan In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome, an MIBG scan may be helpful in the workup for identifying neuroblastoma, ganglioneuroblastoma, or ganglioneuroma as the causative etiology [2,13]. In the absence of any relevant literature, an MIBG scan may not be beneficial as a first-line imaging test in a child presenting with acute ataxia. CT Chest, Abdomen, and Pelvis In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome with concern for neuroblastoma or ganglioneuroblastoma or ganglioneuroma, initial imaging with CT of the chest, abdomen, and pelvis with IV contrast may be helpful for diagnosis, although the clinical utility of CT as an initial imaging modality is less clear [2,13]. | Ataxia Child. MRA Head MRA of the head in conjunction with MRA of the neck may be a helpful tool in assessing ataxia due to posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. MRA Neck MRA of the neck in conjunction with MRA of the head may be a helpful tool in assessing ataxia due to posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. Ataxia-Child MRV Head and Neck There is no relevant literature to support the use of MR venography (MRV) head and neck in the initial evaluation of a child with acute ataxia and no history of recent trauma. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with acute ataxia and no history of recent trauma. MIBG Scan In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome, an MIBG scan may be helpful in the workup for identifying neuroblastoma, ganglioneuroblastoma, or ganglioneuroma as the causative etiology [2,13]. In the absence of any relevant literature, an MIBG scan may not be beneficial as a first-line imaging test in a child presenting with acute ataxia. CT Chest, Abdomen, and Pelvis In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome with concern for neuroblastoma or ganglioneuroblastoma or ganglioneuroma, initial imaging with CT of the chest, abdomen, and pelvis with IV contrast may be helpful for diagnosis, although the clinical utility of CT as an initial imaging modality is less clear [2,13]. | 3158172 |
acrac_3158172_6 | Ataxia Child | MRI Chest, Abdomen, and Pelvis In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome, with clinical suspicion for neuroblastoma, ganglioneuroblastoma, or ganglioneuroma, MRI of the chest, abdomen, and pelvis without and with IV contrast may be helpful to identify the underlying mass [2,13]; however, there is no literature to support the use of this modality as an initial procedure. Variant 2: Child. Acute ataxia, history of recent trauma. Initial imaging. Head trauma is a rare but important cause of ataxia in children, accounting for approximately 5% of acute childhood ataxias [18]. Ataxia after recent head and neck trauma may be due to intracranial hemorrhage, cerebral contusion, concussion, or traumatic vertebral dissection [18,30]. CTA Head and Neck CTA head and neck may be useful in the diagnostic workup of a child presenting with acute ataxia with a recent history of trauma, because of a vertebral artery dissection that may result in a cerebellar stroke and present with ataxia. Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury. CTA Head CTA head in conjunction with CTA of the neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as vertebral artery dissection that may result in a cerebellar stroke and ataxia. Ataxia-Child Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury. CTA Neck CTA neck in conjunction with CTA of the head may be useful in the diagnostic workup if there is suspicion of cervical trauma resulting in cervical vascular injury such as vertebral artery dissection that may result in a cerebellar stroke and ataxia. | Ataxia Child. MRI Chest, Abdomen, and Pelvis In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome, with clinical suspicion for neuroblastoma, ganglioneuroblastoma, or ganglioneuroma, MRI of the chest, abdomen, and pelvis without and with IV contrast may be helpful to identify the underlying mass [2,13]; however, there is no literature to support the use of this modality as an initial procedure. Variant 2: Child. Acute ataxia, history of recent trauma. Initial imaging. Head trauma is a rare but important cause of ataxia in children, accounting for approximately 5% of acute childhood ataxias [18]. Ataxia after recent head and neck trauma may be due to intracranial hemorrhage, cerebral contusion, concussion, or traumatic vertebral dissection [18,30]. CTA Head and Neck CTA head and neck may be useful in the diagnostic workup of a child presenting with acute ataxia with a recent history of trauma, because of a vertebral artery dissection that may result in a cerebellar stroke and present with ataxia. Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury. CTA Head CTA head in conjunction with CTA of the neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as vertebral artery dissection that may result in a cerebellar stroke and ataxia. Ataxia-Child Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury. CTA Neck CTA neck in conjunction with CTA of the head may be useful in the diagnostic workup if there is suspicion of cervical trauma resulting in cervical vascular injury such as vertebral artery dissection that may result in a cerebellar stroke and ataxia. | 3158172 |
acrac_3158172_7 | Ataxia Child | Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with acute ataxia following recent trauma. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy of the head in the initial evaluation of a child with acute ataxia following recent trauma. MRA Head and Neck MRA head and neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury. MRA Head MRA head in conjunction with MRA of the neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury. MRA Neck MRA neck may be useful in the diagnostic workup if there is suspicion of traumatic cervical vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with acute ataxia following recent trauma. | Ataxia Child. Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with acute ataxia following recent trauma. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy of the head in the initial evaluation of a child with acute ataxia following recent trauma. MRA Head and Neck MRA head and neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury. MRA Head MRA head in conjunction with MRA of the neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury. MRA Neck MRA neck may be useful in the diagnostic workup if there is suspicion of traumatic cervical vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with acute ataxia following recent trauma. | 3158172 |
acrac_3158172_8 | Ataxia Child | MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with acute ataxia following recent trauma. Ataxia-Child intermittent ataxia [34]. Recurrent ataxia in a child may be a manifestation of basilar migraines, benign paroxysmal vertigo, genetic disorders such as autosomal dominant episodic ataxia, and metabolic disorders [1,22,25,27,34,35]. Benign paroxysmal vertigo is typically diagnosed by history, physical examination, and when vestibular testing and neuroimaging are normal. Basilar migraines are typically diagnosed based on clinical symptoms and with normal neuroimaging. Autosomal dominant episodic ataxias are a clinically heterogeneous group (at least 6 types described), with imaging findings such as vermian atrophy described in type 2 episodic ataxia. Inborn errors of metabolism, such as intermittent maple syrup urine disease, pyruvate dehydrogenase deficiency, and Hartnup disease can also present with intermittent ataxia during times of stress or illness [1,36,37]; imaging in these cases may be helpful in identifying and characterizing the underlying neurometabolic disease. Children with rotational occlusion of the vertebral artery, also known as bow hunter syndrome, may present with episodic neurologic symptoms including ataxia [38]; however, this condition is rare enough that it is not a diagnostic target for initial evaluation for a child presenting with recurrent ataxia and interval normal neurology examination. CT Head There is no relevant literature to support the use of head CT in the initial evaluation of a child with recurrent ataxia. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with recurrent ataxia. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with recurrent ataxia. | Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with acute ataxia following recent trauma. Ataxia-Child intermittent ataxia [34]. Recurrent ataxia in a child may be a manifestation of basilar migraines, benign paroxysmal vertigo, genetic disorders such as autosomal dominant episodic ataxia, and metabolic disorders [1,22,25,27,34,35]. Benign paroxysmal vertigo is typically diagnosed by history, physical examination, and when vestibular testing and neuroimaging are normal. Basilar migraines are typically diagnosed based on clinical symptoms and with normal neuroimaging. Autosomal dominant episodic ataxias are a clinically heterogeneous group (at least 6 types described), with imaging findings such as vermian atrophy described in type 2 episodic ataxia. Inborn errors of metabolism, such as intermittent maple syrup urine disease, pyruvate dehydrogenase deficiency, and Hartnup disease can also present with intermittent ataxia during times of stress or illness [1,36,37]; imaging in these cases may be helpful in identifying and characterizing the underlying neurometabolic disease. Children with rotational occlusion of the vertebral artery, also known as bow hunter syndrome, may present with episodic neurologic symptoms including ataxia [38]; however, this condition is rare enough that it is not a diagnostic target for initial evaluation for a child presenting with recurrent ataxia and interval normal neurology examination. CT Head There is no relevant literature to support the use of head CT in the initial evaluation of a child with recurrent ataxia. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with recurrent ataxia. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with recurrent ataxia. | 3158172 |
acrac_3158172_9 | Ataxia Child | CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with recurrent ataxia. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with recurrent ataxia. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with recurrent ataxia. MRI Head Although there is inadequate literature regarding the utility of MRI in intermittent or episodic ataxia in childhood, head MRI can be useful in diagnosing metabolic disorders and genetic abnormalities [1,25,34]. Neuroimaging in patients with basilar migraine and childhood benign paroxysmal ataxia is typically normal, and establishing normal neuroimaging supports the diagnosis of these conditions in the appropriate clinical setting [1,25,34]. In these aforementioned causes, there is not enough evidence in the literature to support the use of contrast-enhanced MRI in the initial evaluation of a child with episodic or intermittent ataxia [1,25,34]. MRI Complete Spine There is no relevant literature to support the use of MRI complete spine in the initial evaluation of a child with recurrent ataxia. MR Spectroscopy Head Some episodic ataxias may be due to underlying metabolic disorders, and in specific conditions in which an underlying metabolic disorder is suspected, MR spectroscopy may be useful in investigation. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with recurrent ataxia. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with recurrent ataxia. Ataxia-Child MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with episodic or intermittent ataxia. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with recurrent ataxia. | Ataxia Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with recurrent ataxia. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with recurrent ataxia. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with recurrent ataxia. MRI Head Although there is inadequate literature regarding the utility of MRI in intermittent or episodic ataxia in childhood, head MRI can be useful in diagnosing metabolic disorders and genetic abnormalities [1,25,34]. Neuroimaging in patients with basilar migraine and childhood benign paroxysmal ataxia is typically normal, and establishing normal neuroimaging supports the diagnosis of these conditions in the appropriate clinical setting [1,25,34]. In these aforementioned causes, there is not enough evidence in the literature to support the use of contrast-enhanced MRI in the initial evaluation of a child with episodic or intermittent ataxia [1,25,34]. MRI Complete Spine There is no relevant literature to support the use of MRI complete spine in the initial evaluation of a child with recurrent ataxia. MR Spectroscopy Head Some episodic ataxias may be due to underlying metabolic disorders, and in specific conditions in which an underlying metabolic disorder is suspected, MR spectroscopy may be useful in investigation. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with recurrent ataxia. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with recurrent ataxia. Ataxia-Child MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with episodic or intermittent ataxia. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with recurrent ataxia. | 3158172 |
acrac_3158172_10 | Ataxia Child | MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with recurrent ataxia. Variant 4: Child. Chronic progressive ataxia. Initial imaging. Chronic progressive ataxia is a frequent presentation of ataxia in children. Signs and symptoms are typically of >2 months duration, but occasionally only a few weeks of symptoms may be present [5,14,34]. Cerebellar tumors, brain stem gliomas, and inflammatory disorders are collectively a common cause of chronic progressive ataxia in childhood [1,4,5,25]. Less commonly, inherited ataxias cause chronic progressive ataxias in children [1,4,5,25]. Inherited ataxias are a heterogenous group of clinically and genetically distinguished neurodegenerative disorders, which include autosomal dominant cerebellar ataxias, such as spinocerebellar ataxias, and autosomal recessive cerebellar ataxias, such as Friedreich ataxia. Imaging plays an important role in children with chronic progressive ataxias. Brain imaging is crucial in the assessment of children with suspected brain tumors. In children with inherited chronic progressive ataxias, certain imaging findings can be helpful in the diagnostic workup [1,4,11,28,39-47]. Several hereditary cerebellar ataxias disorders have a progressive clinical course and varying progression of cerebellar hemispheric and vermian volume loss. In addition to cerebellar and vermian atrophy, associated signal abnormality and atrophy of the spinal cord and additional areas of the brain may be seen in certain conditions. Initial imaging provides a baseline for assessment of these abnormalities. Because of the phenotypic heterogeneity and the progressive nature of hereditary cerebellar ataxias, imaging in early childhood may be normal or subtly abnormal with imaging abnormalities becoming more apparent on follow up [14,46,48]. | Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with recurrent ataxia. Variant 4: Child. Chronic progressive ataxia. Initial imaging. Chronic progressive ataxia is a frequent presentation of ataxia in children. Signs and symptoms are typically of >2 months duration, but occasionally only a few weeks of symptoms may be present [5,14,34]. Cerebellar tumors, brain stem gliomas, and inflammatory disorders are collectively a common cause of chronic progressive ataxia in childhood [1,4,5,25]. Less commonly, inherited ataxias cause chronic progressive ataxias in children [1,4,5,25]. Inherited ataxias are a heterogenous group of clinically and genetically distinguished neurodegenerative disorders, which include autosomal dominant cerebellar ataxias, such as spinocerebellar ataxias, and autosomal recessive cerebellar ataxias, such as Friedreich ataxia. Imaging plays an important role in children with chronic progressive ataxias. Brain imaging is crucial in the assessment of children with suspected brain tumors. In children with inherited chronic progressive ataxias, certain imaging findings can be helpful in the diagnostic workup [1,4,11,28,39-47]. Several hereditary cerebellar ataxias disorders have a progressive clinical course and varying progression of cerebellar hemispheric and vermian volume loss. In addition to cerebellar and vermian atrophy, associated signal abnormality and atrophy of the spinal cord and additional areas of the brain may be seen in certain conditions. Initial imaging provides a baseline for assessment of these abnormalities. Because of the phenotypic heterogeneity and the progressive nature of hereditary cerebellar ataxias, imaging in early childhood may be normal or subtly abnormal with imaging abnormalities becoming more apparent on follow up [14,46,48]. | 3158172 |
acrac_3158172_11 | Ataxia Child | CT Head Few studies describe the utility of CT in identifying intracranial calcifications in specific conditions such as Cockayne syndrome, which can present with chronic progressive ataxia in children [14,28]. Although CT may identify major structural abnormalities or intracranial mass lesions, MRI is more sensitive for this purpose. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with chronic progressive ataxia. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with chronic progressive ataxia. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with chronic progressive ataxia. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with chronic progressive ataxia. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with chronic progressive ataxia. MRI Head MRI of the head is useful in the clinical workup of children with chronic progressive ataxia and can identify brain tumors and hereditary neurodegenerative disorders [1,4,11,28,39-47]. In a study of 82 patients with spinocerebellar ataxia type 1, 3, or 6, and 32 normal controls, Schulz et al [46] identified significant atrophy of the brainstem, Ataxia-Child cerebellar vermis, and cerebellar hemispheres in affected children. Contrast-enhanced MRI of the head is useful in characterization of brain tumors that are a common cause of chronic progressive ataxia in children [1,4,5,25]. MRI Complete Spine MRI of the spine may be helpful in children with chronic progressive ataxia due to certain causes, such as central nervous system tumors and spinocerebellar ataxias. Postcontrast imaging may be required depending on case specifics, such as in the setting of central nervous system tumors to identify spinal metastatic disease. | Ataxia Child. CT Head Few studies describe the utility of CT in identifying intracranial calcifications in specific conditions such as Cockayne syndrome, which can present with chronic progressive ataxia in children [14,28]. Although CT may identify major structural abnormalities or intracranial mass lesions, MRI is more sensitive for this purpose. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with chronic progressive ataxia. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with chronic progressive ataxia. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with chronic progressive ataxia. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with chronic progressive ataxia. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with chronic progressive ataxia. MRI Head MRI of the head is useful in the clinical workup of children with chronic progressive ataxia and can identify brain tumors and hereditary neurodegenerative disorders [1,4,11,28,39-47]. In a study of 82 patients with spinocerebellar ataxia type 1, 3, or 6, and 32 normal controls, Schulz et al [46] identified significant atrophy of the brainstem, Ataxia-Child cerebellar vermis, and cerebellar hemispheres in affected children. Contrast-enhanced MRI of the head is useful in characterization of brain tumors that are a common cause of chronic progressive ataxia in children [1,4,5,25]. MRI Complete Spine MRI of the spine may be helpful in children with chronic progressive ataxia due to certain causes, such as central nervous system tumors and spinocerebellar ataxias. Postcontrast imaging may be required depending on case specifics, such as in the setting of central nervous system tumors to identify spinal metastatic disease. | 3158172 |
acrac_3158172_12 | Ataxia Child | MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with chronic progressive ataxia. Altered metabolite ratios or presence of specific metabolites on MR spectroscopy may be useful in distinguishing posterior fossa tumor types and molecular subtypes. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with chronic progressive ataxia. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with chronic progressive ataxia. MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with chronic progressive ataxia. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with chronic progressive ataxia. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with chronic progressive ataxia. Variant 5: Child. Chronic nonprogressive ataxia. Initial imaging. Chronic nonprogressive ataxias are comprised of a heterogenous group of cerebellar ataxias with early onset of cerebellar symptoms and no clinical change in severity during follow-up [1,4,25]. Commonly, symptom onset in these cases is within the first year of life, and this group of ataxias are referred to as chronic nonprogressive congenital ataxia [49]. Chronic nonprogressive ataxia in children may be due to syndromic, nonsyndromic, genetic, and acquired etiologies. In some syndromic causes such as Joubert syndrome and related disorders, ataxia is characteristic [50]. There are genetic causes of nonprogressive congenital ataxia with autosomal dominant, autosomal recessive, and x-linked inheritance patterns but with poor correlation between genotype and phenotype defined by imaging and clinical status [49]. | Ataxia Child. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with chronic progressive ataxia. Altered metabolite ratios or presence of specific metabolites on MR spectroscopy may be useful in distinguishing posterior fossa tumor types and molecular subtypes. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with chronic progressive ataxia. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with chronic progressive ataxia. MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with chronic progressive ataxia. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with chronic progressive ataxia. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with chronic progressive ataxia. Variant 5: Child. Chronic nonprogressive ataxia. Initial imaging. Chronic nonprogressive ataxias are comprised of a heterogenous group of cerebellar ataxias with early onset of cerebellar symptoms and no clinical change in severity during follow-up [1,4,25]. Commonly, symptom onset in these cases is within the first year of life, and this group of ataxias are referred to as chronic nonprogressive congenital ataxia [49]. Chronic nonprogressive ataxia in children may be due to syndromic, nonsyndromic, genetic, and acquired etiologies. In some syndromic causes such as Joubert syndrome and related disorders, ataxia is characteristic [50]. There are genetic causes of nonprogressive congenital ataxia with autosomal dominant, autosomal recessive, and x-linked inheritance patterns but with poor correlation between genotype and phenotype defined by imaging and clinical status [49]. | 3158172 |
acrac_3158172_13 | Ataxia Child | Mutations in the Reelin signaling pathway are one of the autosomal recessive nonprogressive congenital ataxias with marked cerebellar and vermian hypoplasia and gyral simplification [4]. Developmental causes of nonprogressive congenital ataxia include posterior fossa malformations, such as rhombencephalosynapsis, Dandy-Walker syndrome, and Chiari II malformations [4]. Acquired causes of nonprogressive congenital ataxia include prenatally acquired cerebellar injury such as congenital cytomegalovirus infection, in utero cerebellar stroke, and perinatal disrupted development of the cerebellum as can be seen in premature infants and those with perinatal ischemic injury [51]. In the setting of chronic nonprogressive ataxia, imaging can be helpful in identifying the presence of congenital cerebellar, vermian, brainstem, and supratentorial brain malformations and acquired cerebellar disruptions due to prenatal or perinatal insult, although imaging can be normal in genetic etiologies [1,4,25,40]. CT Head Although CT may provide an assessment of major structural abnormalities in the posterior fossa, CT is less sensitive than MRI for assessment of intracranial structures [14,28]. The use of IV contrast is generally not warranted in assessment of brain structural abnormalities that present with chronic nonprogressive ataxia in children. Ataxia-Child CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with chronic nonprogressive ataxia. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with chronic nonprogressive ataxia. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with chronic nonprogressive ataxia. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with chronic nonprogressive ataxia. | Ataxia Child. Mutations in the Reelin signaling pathway are one of the autosomal recessive nonprogressive congenital ataxias with marked cerebellar and vermian hypoplasia and gyral simplification [4]. Developmental causes of nonprogressive congenital ataxia include posterior fossa malformations, such as rhombencephalosynapsis, Dandy-Walker syndrome, and Chiari II malformations [4]. Acquired causes of nonprogressive congenital ataxia include prenatally acquired cerebellar injury such as congenital cytomegalovirus infection, in utero cerebellar stroke, and perinatal disrupted development of the cerebellum as can be seen in premature infants and those with perinatal ischemic injury [51]. In the setting of chronic nonprogressive ataxia, imaging can be helpful in identifying the presence of congenital cerebellar, vermian, brainstem, and supratentorial brain malformations and acquired cerebellar disruptions due to prenatal or perinatal insult, although imaging can be normal in genetic etiologies [1,4,25,40]. CT Head Although CT may provide an assessment of major structural abnormalities in the posterior fossa, CT is less sensitive than MRI for assessment of intracranial structures [14,28]. The use of IV contrast is generally not warranted in assessment of brain structural abnormalities that present with chronic nonprogressive ataxia in children. Ataxia-Child CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with chronic nonprogressive ataxia. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with chronic nonprogressive ataxia. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with chronic nonprogressive ataxia. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with chronic nonprogressive ataxia. | 3158172 |
acrac_3158172_14 | Ataxia Child | CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with chronic nonprogressive ataxia. MRI Head MRI is the most widely utilized imaging method to evaluate chronic nonprogressive ataxia [4,32]. In a child with chronic nonprogressive ataxia, MRI is useful in identifying cerebellar and brainstem malformations to aid diagnosis. Imaging can be particularly useful in the diagnosis of certain syndromic causes of chronic nonprogressive ataxia such as rhombencephalosynapsis, Dandy-Walker or Joubert syndrome, and related disorders that have characteristic imaging findings [50]. Diffusion tensor imaging can facilitate assessment of white matter tract structure in congenital brainstem and cerebellar anomalies [4,6,43,52]. For example, absence of decussation of the superior cerebellar peduncles in Joubert syndrome and abnormal dorsal pontine transverse white matter bundles in pontine tegmental cap dysplasia are seen on diffusion tensor imaging [4]. There is no literature to support the use of IV contrast in this setting. MRI Complete Spine Because some congenital brainstem and cerebellar anomalies that present with chronic nonprogressive ataxia are associated with spinal anomalies, MRI of the complete spine may be helpful in individual cases [44]. There is no literature to support the use of contrast-enhanced imaging of the spine in this scenario. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with chronic nonprogressive ataxia. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with chronic nonprogressive ataxia. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with chronic nonprogressive ataxia. | Ataxia Child. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with chronic nonprogressive ataxia. MRI Head MRI is the most widely utilized imaging method to evaluate chronic nonprogressive ataxia [4,32]. In a child with chronic nonprogressive ataxia, MRI is useful in identifying cerebellar and brainstem malformations to aid diagnosis. Imaging can be particularly useful in the diagnosis of certain syndromic causes of chronic nonprogressive ataxia such as rhombencephalosynapsis, Dandy-Walker or Joubert syndrome, and related disorders that have characteristic imaging findings [50]. Diffusion tensor imaging can facilitate assessment of white matter tract structure in congenital brainstem and cerebellar anomalies [4,6,43,52]. For example, absence of decussation of the superior cerebellar peduncles in Joubert syndrome and abnormal dorsal pontine transverse white matter bundles in pontine tegmental cap dysplasia are seen on diffusion tensor imaging [4]. There is no literature to support the use of IV contrast in this setting. MRI Complete Spine Because some congenital brainstem and cerebellar anomalies that present with chronic nonprogressive ataxia are associated with spinal anomalies, MRI of the complete spine may be helpful in individual cases [44]. There is no literature to support the use of contrast-enhanced imaging of the spine in this scenario. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with chronic nonprogressive ataxia. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with chronic nonprogressive ataxia. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with chronic nonprogressive ataxia. | 3158172 |
acrac_3102399_0 | Postmenopausal Subacute or Chronic Pelvic Pain | Subacute or chronic pelvic pain is a broad clinical presentation common to a variety of gynecologic, urinary, gastrointestinal, and musculoskeletal disorders. There are specific ACR Appropriateness Criteria documents pertaining to many of these diagnoses, which are detailed in Appendix 1. In particular, we emphasize the importance of both vaginal bleeding and suspected adnexal mass in postmenopausal women because of the prevalence of endometrial and ovarian neoplasia in this age group. These clinical features, if present, should take precedence over the general complaint of pelvic pain in directing the management algorithm. Patients with acute pain, suspected pelvic floor dysfunction, or urinary complaints may be managed in accordance with the respective algorithms for those conditions. Imaging evaluation for suspected endometriosis is not considered here as endometriosis is estrogen dependent and usually regresses after menopause [3]. If a postmenopausal woman is experiencing pain from endometriosis, it is likely secondary to scarring or reactivation that is due to postmenopausal hormonal therapy. In cases of persistent endometriosis-related symptoms after menopause, readers are referred to ACR Appropriateness Criteria guidance for the premenopausal age group (see Appendix 1). Finally, like other types of chronic pain, pelvic pain is a complex process with incompletely mapped cognitive and neurologic contributors. As such, there is a growing body of literature regarding potential use of neurologic imaging in patients with chronic pelvic pain [4-7]. However, central nervous system functional imaging remains in the research domain for evaluation of chronic pelvic pain at this time, so we will not consider it formally among the discussed imaging procedures. When all of these aspects of subacute and chronic pelvic pain in postmenopausal women are excluded from direct consideration, a handful of clinically significant conditions remain. | Postmenopausal Subacute or Chronic Pelvic Pain. Subacute or chronic pelvic pain is a broad clinical presentation common to a variety of gynecologic, urinary, gastrointestinal, and musculoskeletal disorders. There are specific ACR Appropriateness Criteria documents pertaining to many of these diagnoses, which are detailed in Appendix 1. In particular, we emphasize the importance of both vaginal bleeding and suspected adnexal mass in postmenopausal women because of the prevalence of endometrial and ovarian neoplasia in this age group. These clinical features, if present, should take precedence over the general complaint of pelvic pain in directing the management algorithm. Patients with acute pain, suspected pelvic floor dysfunction, or urinary complaints may be managed in accordance with the respective algorithms for those conditions. Imaging evaluation for suspected endometriosis is not considered here as endometriosis is estrogen dependent and usually regresses after menopause [3]. If a postmenopausal woman is experiencing pain from endometriosis, it is likely secondary to scarring or reactivation that is due to postmenopausal hormonal therapy. In cases of persistent endometriosis-related symptoms after menopause, readers are referred to ACR Appropriateness Criteria guidance for the premenopausal age group (see Appendix 1). Finally, like other types of chronic pain, pelvic pain is a complex process with incompletely mapped cognitive and neurologic contributors. As such, there is a growing body of literature regarding potential use of neurologic imaging in patients with chronic pelvic pain [4-7]. However, central nervous system functional imaging remains in the research domain for evaluation of chronic pelvic pain at this time, so we will not consider it formally among the discussed imaging procedures. When all of these aspects of subacute and chronic pelvic pain in postmenopausal women are excluded from direct consideration, a handful of clinically significant conditions remain. | 3102399 |
acrac_3102399_1 | Postmenopausal Subacute or Chronic Pelvic Pain | We group these according to location of clinical symptoms: pain localized to the deep or internal pelvis, with potential etiologies and associated conditions, including pelvic venous disorders (commonly termed pelvic congestion syndrome), intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis versus chronic pain localized to the perineum, vulva, or vagina that arises from suspected vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Special Imaging Considerations When there is suspected local pathology in the vulva, perineum, or vaginal wall, translabial/transperineal ultrasound (US) or side-firing transvaginal probes may provide better visualization than end-firing transvaginal 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] Postmenopausal Subacute or Chronic Pelvic Pain US probes [8]. There is scant evidence for imaging recommendations at this level of specificity, and it is assumed that the performing sonographer and sonologist will make appropriate technical adjustments to optimize imaging in these relatively uncommon clinical scenarios. Discussion of Procedures by Variant Variant 1: Postmenopausal subacute or chronic pelvic pain, localized to the deep pelvis. Initial imaging. Radiography Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of radiography to evaluate postmenopausal subacute or chronic pelvic pain localized to the deep pelvis. | Postmenopausal Subacute or Chronic Pelvic Pain. We group these according to location of clinical symptoms: pain localized to the deep or internal pelvis, with potential etiologies and associated conditions, including pelvic venous disorders (commonly termed pelvic congestion syndrome), intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis versus chronic pain localized to the perineum, vulva, or vagina that arises from suspected vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Special Imaging Considerations When there is suspected local pathology in the vulva, perineum, or vaginal wall, translabial/transperineal ultrasound (US) or side-firing transvaginal probes may provide better visualization than end-firing transvaginal 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] Postmenopausal Subacute or Chronic Pelvic Pain US probes [8]. There is scant evidence for imaging recommendations at this level of specificity, and it is assumed that the performing sonographer and sonologist will make appropriate technical adjustments to optimize imaging in these relatively uncommon clinical scenarios. Discussion of Procedures by Variant Variant 1: Postmenopausal subacute or chronic pelvic pain, localized to the deep pelvis. Initial imaging. Radiography Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of radiography to evaluate postmenopausal subacute or chronic pelvic pain localized to the deep pelvis. | 3102399 |
acrac_3102399_2 | Postmenopausal Subacute or Chronic Pelvic Pain | US Pelvis Transvaginal Pelvic US using a combined transabdominal and transvaginal approach is the initial imaging study of choice to evaluate postmenopausal subacute or chronic pelvic pain localized to the deep pelvis [9-12]. US can provide anatomic information about uterine size and endometrial canal distension, fallopian tube dilation, ovaries, and adnexal masses. Regarding the sequencing of examinations, several authors have pointed out that if the etiology of pelvic pain remains obscure after CT, a subsequent US has the capacity to provide additional information about the adnexa in particular [13,14]. US is broadly used and clinically accepted worldwide. However, high-quality evidence, such as clinical trials supporting specific usefulness of US, is lacking. Chronic pelvic inflammatory disease may be associated with pelvic fluid, hydrosalpinx or pyosalpinx, inflammatory adnexal masses, and peritoneal inclusions visible by US [15]. When pelvic adhesions are suspected, real-time dynamic US or cine clips may document abnormal adherence or lack of mobility of structures, particularly transvaginally. However, adhesive disease is a notoriously difficult diagnosis to confirm nonoperatively [16], and the evidence basis is anecdotal [15,17]. Furthermore, the causal linkage between adhesive disease and chronic pelvic pain remains unclear. Many women with pelvic venous disorders have morphologic findings of polycystic ovarian syndrome (enlarged ovaries with exaggerated central stroma and multiple small peripherally located follicles), but the associated clinical features of hirsutism and amenorrhea are rare [11,18]. Multiple investigators have identified a component of estrogen overstimulation in pelvic venous disorders, and symptoms may subside after menopause in some women [15]. There is a lack of clear definition and high-quality evidence in the clinical domain of pelvic venous disorders. | Postmenopausal Subacute or Chronic Pelvic Pain. US Pelvis Transvaginal Pelvic US using a combined transabdominal and transvaginal approach is the initial imaging study of choice to evaluate postmenopausal subacute or chronic pelvic pain localized to the deep pelvis [9-12]. US can provide anatomic information about uterine size and endometrial canal distension, fallopian tube dilation, ovaries, and adnexal masses. Regarding the sequencing of examinations, several authors have pointed out that if the etiology of pelvic pain remains obscure after CT, a subsequent US has the capacity to provide additional information about the adnexa in particular [13,14]. US is broadly used and clinically accepted worldwide. However, high-quality evidence, such as clinical trials supporting specific usefulness of US, is lacking. Chronic pelvic inflammatory disease may be associated with pelvic fluid, hydrosalpinx or pyosalpinx, inflammatory adnexal masses, and peritoneal inclusions visible by US [15]. When pelvic adhesions are suspected, real-time dynamic US or cine clips may document abnormal adherence or lack of mobility of structures, particularly transvaginally. However, adhesive disease is a notoriously difficult diagnosis to confirm nonoperatively [16], and the evidence basis is anecdotal [15,17]. Furthermore, the causal linkage between adhesive disease and chronic pelvic pain remains unclear. Many women with pelvic venous disorders have morphologic findings of polycystic ovarian syndrome (enlarged ovaries with exaggerated central stroma and multiple small peripherally located follicles), but the associated clinical features of hirsutism and amenorrhea are rare [11,18]. Multiple investigators have identified a component of estrogen overstimulation in pelvic venous disorders, and symptoms may subside after menopause in some women [15]. There is a lack of clear definition and high-quality evidence in the clinical domain of pelvic venous disorders. | 3102399 |
acrac_3102399_3 | Postmenopausal Subacute or Chronic Pelvic Pain | CT Abdomen and Pelvis When pelvic venous disorders are clinically suspected, contrast-enhanced CT of the abdomen and pelvis may demonstrate engorged periuterine and periovarian veins, venous anatomic variants, and occasional compression of the left renal vein resulting in asymmetric left-sided pelvic varicosities [10,19-22]. However, CT lacks the capacity of US or MR to provide dynamic flow information [18]. CT Pelvis When pelvic venous disorders are clinically suspected, contrast-enhanced CT of the pelvis may demonstrate engorged periuterine and periovarian veins, although their drainage into the renal vein or cava will not be evaluated without CT coverage of the abdomen [10,19-22]. In chronic inflammatory disease, CT may demonstrate pelvic fluid, peritoneal thickening, hydrosalpinx or pyosalpinx, and tubo-ovarian abscess [23]. MRI Pelvis MRI is widely regarded as the problem-solving imaging examination of choice for chronic pelvic pain, particularly when US findings are nondiagnostic or inconclusive [11,15,24]. When MRI is clinically indicated, the use of a gadolinium-based IV contrast agent is preferred. Please see the ACR Manual on Contrast Media for additional information [25]. The diagnostic performance of MRI/MR angiography is comparable to conventional venography for identifying pelvic venous disorders [26,27]. The use of MRI for this indication is growing accordingly [28], necessitating standardized interpretation and reporting [29]. T2-weighted imaging has the capacity to demonstrate pelvic varices, but signal intensity varies with flow velocity. Vein conspicuity and flow directional assessment are superior using time-resolved postcontrast T1-weighted imaging, which can directly demonstrate ovarian vein reflux [10,30]. Noninvasive imaging with MRI has largely supplanted conventional venography for diagnostic purposes, but venography may still be performed in the context of intended intervention. | Postmenopausal Subacute or Chronic Pelvic Pain. CT Abdomen and Pelvis When pelvic venous disorders are clinically suspected, contrast-enhanced CT of the abdomen and pelvis may demonstrate engorged periuterine and periovarian veins, venous anatomic variants, and occasional compression of the left renal vein resulting in asymmetric left-sided pelvic varicosities [10,19-22]. However, CT lacks the capacity of US or MR to provide dynamic flow information [18]. CT Pelvis When pelvic venous disorders are clinically suspected, contrast-enhanced CT of the pelvis may demonstrate engorged periuterine and periovarian veins, although their drainage into the renal vein or cava will not be evaluated without CT coverage of the abdomen [10,19-22]. In chronic inflammatory disease, CT may demonstrate pelvic fluid, peritoneal thickening, hydrosalpinx or pyosalpinx, and tubo-ovarian abscess [23]. MRI Pelvis MRI is widely regarded as the problem-solving imaging examination of choice for chronic pelvic pain, particularly when US findings are nondiagnostic or inconclusive [11,15,24]. When MRI is clinically indicated, the use of a gadolinium-based IV contrast agent is preferred. Please see the ACR Manual on Contrast Media for additional information [25]. The diagnostic performance of MRI/MR angiography is comparable to conventional venography for identifying pelvic venous disorders [26,27]. The use of MRI for this indication is growing accordingly [28], necessitating standardized interpretation and reporting [29]. T2-weighted imaging has the capacity to demonstrate pelvic varices, but signal intensity varies with flow velocity. Vein conspicuity and flow directional assessment are superior using time-resolved postcontrast T1-weighted imaging, which can directly demonstrate ovarian vein reflux [10,30]. Noninvasive imaging with MRI has largely supplanted conventional venography for diagnostic purposes, but venography may still be performed in the context of intended intervention. | 3102399 |
acrac_3102399_4 | Postmenopausal Subacute or Chronic Pelvic Pain | In chronic pelvic inflammatory disease, MRI with T2-weighted imaging may demonstrate edema, fluid collections, and distension of endometrial canal or fallopian tubes [15]. When infection is long standing, distinguishing between inflammatory and neoplastic masses is particularly difficult. Postcontrast T1-weighted imaging and diffusion-weighted imaging are particularly important in this setting [23]. Adhesive disease may be directly evident at MRI as low-signal bands between structures on nonfat saturated T2-weighted imaging or inferred in the presence of peritoneal inclusion cysts [11,15]. Variant 2: Postmenopausal subacute or chronic pelvic pain, clinically suspected pathologies in perineum, vulva, or vagina. Initial imaging. Physical examination is the foundation of clinical evaluation of suspected pathology in the perineum, vulva, or vagina. The evidence supporting the use of imaging procedures in this clinical context largely assumes that the physical examination is abnormal. Radiography Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of radiography to evaluate postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina. US Pelvis Transvaginal Physical examination is the basis of diagnosis for most conditions localized to the vulvar skin [31]. Perineal and vaginal cysts are subcutaneous but often palpable and are appropriately evaluated with either translabial or transvaginal US, or both [8]. As with pelvic pain localized to the deep pelvis, US is widely regarded as the initial imaging study of choice for pelvic pain localized to the perineum, vulva, or vagina, but there is little high-quality evidence specifically supporting its use. Postmenopausal Subacute or Chronic Pelvic Pain US Duplex Doppler Pelvis Color and spectral Doppler are routinely used in pelvic sonography to evaluate internal vascularity of pelvic observations and distinguish cysts from soft tissue. | Postmenopausal Subacute or Chronic Pelvic Pain. In chronic pelvic inflammatory disease, MRI with T2-weighted imaging may demonstrate edema, fluid collections, and distension of endometrial canal or fallopian tubes [15]. When infection is long standing, distinguishing between inflammatory and neoplastic masses is particularly difficult. Postcontrast T1-weighted imaging and diffusion-weighted imaging are particularly important in this setting [23]. Adhesive disease may be directly evident at MRI as low-signal bands between structures on nonfat saturated T2-weighted imaging or inferred in the presence of peritoneal inclusion cysts [11,15]. Variant 2: Postmenopausal subacute or chronic pelvic pain, clinically suspected pathologies in perineum, vulva, or vagina. Initial imaging. Physical examination is the foundation of clinical evaluation of suspected pathology in the perineum, vulva, or vagina. The evidence supporting the use of imaging procedures in this clinical context largely assumes that the physical examination is abnormal. Radiography Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of radiography to evaluate postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina. US Pelvis Transvaginal Physical examination is the basis of diagnosis for most conditions localized to the vulvar skin [31]. Perineal and vaginal cysts are subcutaneous but often palpable and are appropriately evaluated with either translabial or transvaginal US, or both [8]. As with pelvic pain localized to the deep pelvis, US is widely regarded as the initial imaging study of choice for pelvic pain localized to the perineum, vulva, or vagina, but there is little high-quality evidence specifically supporting its use. Postmenopausal Subacute or Chronic Pelvic Pain US Duplex Doppler Pelvis Color and spectral Doppler are routinely used in pelvic sonography to evaluate internal vascularity of pelvic observations and distinguish cysts from soft tissue. | 3102399 |
acrac_3102399_5 | Postmenopausal Subacute or Chronic Pelvic Pain | Although it is rated as a separate imaging procedure per ACR methodology, the expert panel considers Doppler imaging to be a standard component of pelvic sonography. Special considerations for women with chronic pelvic pain may include evaluation of uterine artery blood flow, with low-resistance waveforms having been described in women with chronic pelvic pain [12]. CT Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of CT for primary evaluation of postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina. CT Pelvis To our knowledge, there is currently no evidence to support the use of CT for primary evaluation of postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina. MRI Pelvis When MRI is clinically indicated, the use of a gadolinium-based IV contrast agent is preferred. Please see the ACR Manual on Contrast Media for additional information [25]. When a cyst or mass is identified by US in the perineum, vulva, or vagina, MRI provides additional anatomic detail and evaluation of any enhancing soft-tissue components that might favor infection or neoplasia [11,24,32,33]. MRI has an important role as a problem-solving examination for lesion characterization and surgical planning, but there is, to our knowledge, no direct evidence to support the use of MRI as the initial or primary imaging examination for evaluation of pelvic pain localized to the perineum, vulva, or vagina, particularly when the physical examination is normal. However, there is emerging evidence to support the first- line utility of MRI when endometriosis or fistulizing disease are suspected [34]; readers are again referred to specific ACR Appropriateness Criteria guidelines for these clinical scenarios (see Appendix 1). MRI also enables accurate depiction of pelvic floor muscular anatomy, integrity, and function [35,36]. | Postmenopausal Subacute or Chronic Pelvic Pain. Although it is rated as a separate imaging procedure per ACR methodology, the expert panel considers Doppler imaging to be a standard component of pelvic sonography. Special considerations for women with chronic pelvic pain may include evaluation of uterine artery blood flow, with low-resistance waveforms having been described in women with chronic pelvic pain [12]. CT Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of CT for primary evaluation of postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina. CT Pelvis To our knowledge, there is currently no evidence to support the use of CT for primary evaluation of postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina. MRI Pelvis When MRI is clinically indicated, the use of a gadolinium-based IV contrast agent is preferred. Please see the ACR Manual on Contrast Media for additional information [25]. When a cyst or mass is identified by US in the perineum, vulva, or vagina, MRI provides additional anatomic detail and evaluation of any enhancing soft-tissue components that might favor infection or neoplasia [11,24,32,33]. MRI has an important role as a problem-solving examination for lesion characterization and surgical planning, but there is, to our knowledge, no direct evidence to support the use of MRI as the initial or primary imaging examination for evaluation of pelvic pain localized to the perineum, vulva, or vagina, particularly when the physical examination is normal. However, there is emerging evidence to support the first- line utility of MRI when endometriosis or fistulizing disease are suspected [34]; readers are again referred to specific ACR Appropriateness Criteria guidelines for these clinical scenarios (see Appendix 1). MRI also enables accurate depiction of pelvic floor muscular anatomy, integrity, and function [35,36]. | 3102399 |
acrac_3082597_0 | Nontraumatic Aortic Disease | Introduction/Background Nontraumatic aortic disease can be caused by a wide variety of disorders, including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative diseases. Such conditions include, but are not limited to, atherosclerosis, aortic dissection, intramural hematoma, penetrating aortic ulcer, aortic aneurysms of various etiologies (degenerative, mycotic, or vasculitis-related), aortic rupture, thrombosis, aortobronchial fistula, congenital disorders, and extrinsic compression from adjacent masses. Diagnostic imaging is essential to assess the anatomy and extent of morphological changes involving the aorta. Nontraumatic aortic diseases may affect the lumen, wall, or perivascular structures. When there is aortic branch vessel involvement, end organ perfusion may be compromised. Often, aortic disorders involve both the thoracic and abdominal aortic segments, thus requiring imaging of both regions. The clinical symptoms of aortic diseases vary widely. For example, acute aortic syndrome presents acutely with chest pain and elevated blood pressure, whereas atherosclerosis may be asymptomatic and detected incidentally. 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. aUniversity of Alabama at Birmingham, Birmingham, Alabama. bPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. cPanel Vice-Chair, Emory Healthcare, Atlanta, Georgia. dSt. Francis Hospital, Catholic Health Services of Long Island, Roslyn, New York; Society for Cardiovascular Magnetic Resonance. eTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. | Nontraumatic Aortic Disease. Introduction/Background Nontraumatic aortic disease can be caused by a wide variety of disorders, including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative diseases. Such conditions include, but are not limited to, atherosclerosis, aortic dissection, intramural hematoma, penetrating aortic ulcer, aortic aneurysms of various etiologies (degenerative, mycotic, or vasculitis-related), aortic rupture, thrombosis, aortobronchial fistula, congenital disorders, and extrinsic compression from adjacent masses. Diagnostic imaging is essential to assess the anatomy and extent of morphological changes involving the aorta. Nontraumatic aortic diseases may affect the lumen, wall, or perivascular structures. When there is aortic branch vessel involvement, end organ perfusion may be compromised. Often, aortic disorders involve both the thoracic and abdominal aortic segments, thus requiring imaging of both regions. The clinical symptoms of aortic diseases vary widely. For example, acute aortic syndrome presents acutely with chest pain and elevated blood pressure, whereas atherosclerosis may be asymptomatic and detected incidentally. 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. aUniversity of Alabama at Birmingham, Birmingham, Alabama. bPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. cPanel Vice-Chair, Emory Healthcare, Atlanta, Georgia. dSt. Francis Hospital, Catholic Health Services of Long Island, Roslyn, New York; Society for Cardiovascular Magnetic Resonance. eTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. | 3082597 |
acrac_3082597_1 | Nontraumatic Aortic Disease | fKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. gMassachusetts General Hospital, Boston, Massachusetts. hMayo Clinic, Rochester, Minnesota. iUniversity of Virginia, Charlottesville, Virginia. jLoyola University Medical Center, Maywood, Illinois. kThe Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert. lMassachusetts General Hospital, Boston, Massachusetts. mUT Southwestern Medical Center, Dallas, Texas. nStanford University Medical Center, Stanford, California. oSpecialty Chair, Emory University Hospital, Atlanta, Georgia. 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: Congenital aortic disease. Initial imaging. Aortography Chest and Abdomen Catheter-based aortography is considered the reference standard for the diagnosis of congenital aortic diseases [10]. Aortography provides information regarding flow and allows hemodynamic measurements to be taken; however, several noninvasive studies can provide similar information. As such, the role of aortography in diagnosing aortic diseases is decreasing as the sensitivity of other noninvasive modalities, such as transthoracic echocardiography (TTE), CTA, and MR angiography (MRA) improves [11-18]. Aortography is now most commonly performed when an intervention is planned. CT Chest and Abdomen There is no relevant literature available to examine the use of CT chest and abdomen with intravenous (IV) contrast alone in the management of congenital aortic disease. | Nontraumatic Aortic Disease. fKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. gMassachusetts General Hospital, Boston, Massachusetts. hMayo Clinic, Rochester, Minnesota. iUniversity of Virginia, Charlottesville, Virginia. jLoyola University Medical Center, Maywood, Illinois. kThe Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert. lMassachusetts General Hospital, Boston, Massachusetts. mUT Southwestern Medical Center, Dallas, Texas. nStanford University Medical Center, Stanford, California. oSpecialty Chair, Emory University Hospital, Atlanta, Georgia. 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: Congenital aortic disease. Initial imaging. Aortography Chest and Abdomen Catheter-based aortography is considered the reference standard for the diagnosis of congenital aortic diseases [10]. Aortography provides information regarding flow and allows hemodynamic measurements to be taken; however, several noninvasive studies can provide similar information. As such, the role of aortography in diagnosing aortic diseases is decreasing as the sensitivity of other noninvasive modalities, such as transthoracic echocardiography (TTE), CTA, and MR angiography (MRA) improves [11-18]. Aortography is now most commonly performed when an intervention is planned. CT Chest and Abdomen There is no relevant literature available to examine the use of CT chest and abdomen with intravenous (IV) contrast alone in the management of congenital aortic disease. | 3082597 |
acrac_3082597_2 | Nontraumatic Aortic Disease | There is no relevant literature available to examine the use of CT chest and abdomen without and with IV contrast in the management of congenital aortic disease. CTA Chest and Abdomen with IV Contrast As a modality, CTA provides excellent spatial resolution, fast acquisition times, and the ability for 3-D reconstruction [6,16]. Another advantage of CTA is the ability to visualize cardiac structures and coronary arteries, as several congenital aortic processes are associated with cardiac abnormalities [19]. One study found that a prospectively triggered, dual-energy, high-pitch protocol CTA was more accurate than echocardiography in the diagnosis of coarctation [20]. Another series found CTA to be 100% accurate compared with operative findings in evaluating the diameter and length of aortic coarctation [18], whereas others have demonstrated CTA to compare favorably to both operative and catheter-based angiographic findings [11-14]. These findings make CTA a valuable, noninvasive imaging study for aortic characterization that can help to guide future interventions [19]. However, CTA does not provide direct hemodynamic information [10]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature for the use of PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)- PET/CT imaging in the evaluation of congenital aortic disease. MRA Chest and Abdomen The relevant literature focuses on cardiac MRI, rather than MRA of the chest and abdomen, for evaluating congenital aortic disease. Cardiac MRI is becoming standard practice in evaluating patients with suspected congenital aortic pathology [21]. Even though it has lower spatial resolution than CT, MRA provides important physiologic information, including pressure gradients, extent of collateral flow, contractility of the myocardium, and evaluation of the valves [22]. | Nontraumatic Aortic Disease. There is no relevant literature available to examine the use of CT chest and abdomen without and with IV contrast in the management of congenital aortic disease. CTA Chest and Abdomen with IV Contrast As a modality, CTA provides excellent spatial resolution, fast acquisition times, and the ability for 3-D reconstruction [6,16]. Another advantage of CTA is the ability to visualize cardiac structures and coronary arteries, as several congenital aortic processes are associated with cardiac abnormalities [19]. One study found that a prospectively triggered, dual-energy, high-pitch protocol CTA was more accurate than echocardiography in the diagnosis of coarctation [20]. Another series found CTA to be 100% accurate compared with operative findings in evaluating the diameter and length of aortic coarctation [18], whereas others have demonstrated CTA to compare favorably to both operative and catheter-based angiographic findings [11-14]. These findings make CTA a valuable, noninvasive imaging study for aortic characterization that can help to guide future interventions [19]. However, CTA does not provide direct hemodynamic information [10]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature for the use of PET using the tracer fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)- PET/CT imaging in the evaluation of congenital aortic disease. MRA Chest and Abdomen The relevant literature focuses on cardiac MRI, rather than MRA of the chest and abdomen, for evaluating congenital aortic disease. Cardiac MRI is becoming standard practice in evaluating patients with suspected congenital aortic pathology [21]. Even though it has lower spatial resolution than CT, MRA provides important physiologic information, including pressure gradients, extent of collateral flow, contractility of the myocardium, and evaluation of the valves [22]. | 3082597 |
acrac_3082597_3 | Nontraumatic Aortic Disease | Physiologic measurements are especially critical in evaluating coarctation where the smallest cross-sectional diameter of the aorta and flow deceleration in the descending aorta measured on velocity-encoded cine MRI are excellent predictors of a hemodynamically significant stenosis [15,17]. Newer 4-D sequences may improve the evaluation of vascular flow and hemodynamics, such as shear stress, pressure gradients, and turbulence [23-25]. Because of cardiac motion, 3-D noncontrast navigator MRA, steady-state 3-D contrast- enhanced MRA, or gated first-pass contrast-enhanced MRA is preferable to evaluate the aortic root [26,27]. Nontraumatic Aortic Disease The addition of IV contrast for MRA can be beneficial in evaluating congenital aortic diseases. For example, contrast-enhanced MRA has a higher sensitivity, specificity, and accuracy for detecting obstructive aortic anomalies when compared with either TTE or MRA without IV contrast [28]. Contrast-enhanced MRA may also improve visualization of the aorta when compared with fast spin-echo sequences [29]. US Echocardiography Transthoracic TTE is a useful modality during the evaluation of congenital aortic abnormalities, given its association with cardiac abnormalities. For example, the reported incidence of bicuspid aortic valve in the setting of aortic coarctation ranges from 30% to 40% [19]. TTE is often the initial imaging modality when coarctation of the aorta is suspected [16], even though its utility can be reduced in the adult population because of its limited acoustic windows [21]. These limitations can be overcome somewhat through the use of the suprasternal view and Doppler imaging [20]. In addition to anatomic information, TTE can provide valuable physiologic parameters. For instance, Doppler can estimate peak velocities and pressure gradients across a stenosis [39,40]. TTE can also provide information regarding cardiac contractility, direction of flow, and valvular disorders [41]. | Nontraumatic Aortic Disease. Physiologic measurements are especially critical in evaluating coarctation where the smallest cross-sectional diameter of the aorta and flow deceleration in the descending aorta measured on velocity-encoded cine MRI are excellent predictors of a hemodynamically significant stenosis [15,17]. Newer 4-D sequences may improve the evaluation of vascular flow and hemodynamics, such as shear stress, pressure gradients, and turbulence [23-25]. Because of cardiac motion, 3-D noncontrast navigator MRA, steady-state 3-D contrast- enhanced MRA, or gated first-pass contrast-enhanced MRA is preferable to evaluate the aortic root [26,27]. Nontraumatic Aortic Disease The addition of IV contrast for MRA can be beneficial in evaluating congenital aortic diseases. For example, contrast-enhanced MRA has a higher sensitivity, specificity, and accuracy for detecting obstructive aortic anomalies when compared with either TTE or MRA without IV contrast [28]. Contrast-enhanced MRA may also improve visualization of the aorta when compared with fast spin-echo sequences [29]. US Echocardiography Transthoracic TTE is a useful modality during the evaluation of congenital aortic abnormalities, given its association with cardiac abnormalities. For example, the reported incidence of bicuspid aortic valve in the setting of aortic coarctation ranges from 30% to 40% [19]. TTE is often the initial imaging modality when coarctation of the aorta is suspected [16], even though its utility can be reduced in the adult population because of its limited acoustic windows [21]. These limitations can be overcome somewhat through the use of the suprasternal view and Doppler imaging [20]. In addition to anatomic information, TTE can provide valuable physiologic parameters. For instance, Doppler can estimate peak velocities and pressure gradients across a stenosis [39,40]. TTE can also provide information regarding cardiac contractility, direction of flow, and valvular disorders [41]. | 3082597 |
acrac_3082597_4 | Nontraumatic Aortic Disease | Despite these advantages, TTE is limited in its ability to evaluate the aortic arch and proximal descending aorta [42,43]. US Echocardiography Transesophageal Transesophageal echocardiography (TEE) can provide views of the descending aorta, but physiologic information derived from these views can be inaccurate [21]. TEE is invasive and may not provide additional information than that gained from TTE [10]. Variant 2: Inflammatory or infectious or neoplastic or metabolic nontraumatic aortic disease. Initial imaging. Aortography Chest and Abdomen Catheter-based aortography provides high spatial and temporal resolution, but because of its invasive nature and inability to detect changes to the vessel wall, it is considered inferior to cross-sectional imaging modalities. For example, a recent meta-analysis found that CT, MRI, and US were better than catheter-based angiography in detecting vascular lesions resulting from Takayasu arteritis [44]. Aortography is of most benefit when an intervention is planned. Overall, the addition of a contrast-enhanced CT scan after an unenhanced CT scan may be of benefit. For suspected vascular infection, one small series found rim enhancement to be the only finding associated with infection that required the administration of IV contrast [45]. Other findings in this series associated with infection did not need Nontraumatic Aortic Disease For suspected vascular infection, CT imaging without IV contrast has some value in identifying signs associated with infection, including perivascular stranding, gas, wall thickening, aneurysmal dilatation, and involvement of adjacent bony structures [45,48]. Similarly, periaortic hemorrhage from ruptured aneurysm can be identified on CT without IV contrast [49]. Benign and malignant aortic tumors are exceedingly rare and often difficult to prospectively diagnose on imaging [50]. For suspected primary vascular neoplasms, an irregular soft-tissue density adjacent to the vessel wall may be seen [46,47]. | Nontraumatic Aortic Disease. Despite these advantages, TTE is limited in its ability to evaluate the aortic arch and proximal descending aorta [42,43]. US Echocardiography Transesophageal Transesophageal echocardiography (TEE) can provide views of the descending aorta, but physiologic information derived from these views can be inaccurate [21]. TEE is invasive and may not provide additional information than that gained from TTE [10]. Variant 2: Inflammatory or infectious or neoplastic or metabolic nontraumatic aortic disease. Initial imaging. Aortography Chest and Abdomen Catheter-based aortography provides high spatial and temporal resolution, but because of its invasive nature and inability to detect changes to the vessel wall, it is considered inferior to cross-sectional imaging modalities. For example, a recent meta-analysis found that CT, MRI, and US were better than catheter-based angiography in detecting vascular lesions resulting from Takayasu arteritis [44]. Aortography is of most benefit when an intervention is planned. Overall, the addition of a contrast-enhanced CT scan after an unenhanced CT scan may be of benefit. For suspected vascular infection, one small series found rim enhancement to be the only finding associated with infection that required the administration of IV contrast [45]. Other findings in this series associated with infection did not need Nontraumatic Aortic Disease For suspected vascular infection, CT imaging without IV contrast has some value in identifying signs associated with infection, including perivascular stranding, gas, wall thickening, aneurysmal dilatation, and involvement of adjacent bony structures [45,48]. Similarly, periaortic hemorrhage from ruptured aneurysm can be identified on CT without IV contrast [49]. Benign and malignant aortic tumors are exceedingly rare and often difficult to prospectively diagnose on imaging [50]. For suspected primary vascular neoplasms, an irregular soft-tissue density adjacent to the vessel wall may be seen [46,47]. | 3082597 |
acrac_3082597_5 | Nontraumatic Aortic Disease | CT imaging without IV contrast has little value in the diagnosis of inflammatory or metabolic aortic diseases. MRA Chest and Abdomen Contrast-enhanced MRA techniques have evolved with the introduction of k-space and image-based acceleration techniques, higher field strengths, ultra-fast gradients, and the use of 3-D gradient-echo techniques. Double or triple inversion recovery and balanced steady-state free-precession pulse sequences are acquired before applying contrast- enhanced MRA. Additionally, delayed high-resolution T1-weighted images are acquired to assess aortic wall enhancement, especially in the cases of suspected inflammatory or infectious processes. Contrast-enhanced MRI can be particularly useful in the evaluation of inflammatory conditions as it can detect wall enhancement, which is a sign of active Takayasu arteritis [66]. Moreover, a recent meta-analysis reported that the addition of contrast- enhanced sequences improved the sensitivity of MRA in detecting Takayasu arteritis from 79% to 92% [44]. The same study showed that contrast-enhanced MRA outperformed catheter-based angiography. Similarly, contrast- enhanced MRI allows for improved detection of wall enhancement in both GCA [67-70] and Behcet disease [55,71]. For suspected neoplasms, contrast-enhanced MRI may be able to help differentiate between atheromatous plaque and tumor as well as help to delineate extravascular extension [72]. Regarding infection, the utility of contrast- enhanced MRA is similar to that of CTA in its ability to detect aneurysms, edema, perivascular stranding, gas, and disrupted calcifications [50]. MRA without IV contrast has some utility in the diagnosis of inflammatory vascular conditions. For example, one meta-analysis found MRA to be 79% sensitive and 97% specific in the diagnosis of Takayasu arteritis, outperforming catheter-based angiography [44]. MRA without IV contrast is able to identify extracranial Nontraumatic Aortic Disease involvement in GCA [73]. | Nontraumatic Aortic Disease. CT imaging without IV contrast has little value in the diagnosis of inflammatory or metabolic aortic diseases. MRA Chest and Abdomen Contrast-enhanced MRA techniques have evolved with the introduction of k-space and image-based acceleration techniques, higher field strengths, ultra-fast gradients, and the use of 3-D gradient-echo techniques. Double or triple inversion recovery and balanced steady-state free-precession pulse sequences are acquired before applying contrast- enhanced MRA. Additionally, delayed high-resolution T1-weighted images are acquired to assess aortic wall enhancement, especially in the cases of suspected inflammatory or infectious processes. Contrast-enhanced MRI can be particularly useful in the evaluation of inflammatory conditions as it can detect wall enhancement, which is a sign of active Takayasu arteritis [66]. Moreover, a recent meta-analysis reported that the addition of contrast- enhanced sequences improved the sensitivity of MRA in detecting Takayasu arteritis from 79% to 92% [44]. The same study showed that contrast-enhanced MRA outperformed catheter-based angiography. Similarly, contrast- enhanced MRI allows for improved detection of wall enhancement in both GCA [67-70] and Behcet disease [55,71]. For suspected neoplasms, contrast-enhanced MRI may be able to help differentiate between atheromatous plaque and tumor as well as help to delineate extravascular extension [72]. Regarding infection, the utility of contrast- enhanced MRA is similar to that of CTA in its ability to detect aneurysms, edema, perivascular stranding, gas, and disrupted calcifications [50]. MRA without IV contrast has some utility in the diagnosis of inflammatory vascular conditions. For example, one meta-analysis found MRA to be 79% sensitive and 97% specific in the diagnosis of Takayasu arteritis, outperforming catheter-based angiography [44]. MRA without IV contrast is able to identify extracranial Nontraumatic Aortic Disease involvement in GCA [73]. | 3082597 |
acrac_3082597_6 | Nontraumatic Aortic Disease | As discussed above, this modality is unable to provide an assessment of wall enhancement, which is an important marker in many inflammatory conditions. Similar to unenhanced CT, MRA without IV contrast is able to identify aneurysms, edema, perivascular stranding, gas, and disrupted calcifications that may be associated with aortic infections [50]. For suspected neoplasms, an irregular soft-tissue structure may be identified that may or may not enhance after IV contrast administration [46,47]. Radiography Chest Chest radiography may be helpful in evaluating the contour, size, and location of the thoracic aorta and the great vessels, which, if abnormal, would prompt further investigation [10,21]. Radiography is not considered an adequate modality to evaluate for inflammatory, infectious, neoplastic, or metabolic aortic diseases. Vascular duplex US can identify vascular wall thickening, which is an important marker in patients with generalized vascular inflammation [74], GCA [73,75], Behcet disease [76], and Takayasu arteritis [44]. Additionally, US is better than catheter-based angiography for detecting stenoses, occlusions, and aneurysms from Takayasu arteritis [44]. Nonetheless, it must be remembered that these evaluations primarily focused on nonaortic vessels. In fact, one study compared duplex US to FDG-PET/CT for the detection of extracranial large vessel vasculitis and found that US was only 26% sensitive for detecting aortic involvement. Other authors have also recognized the limitations of US for measuring wall thickness of the aorta [44,75]. For suspected neoplastic processes, US is of little value because it is not able to reliably differentiate between malignant and benign tissue [50]. There is no relevant literature available to examine the use of US in suspected aortic infection. | Nontraumatic Aortic Disease. As discussed above, this modality is unable to provide an assessment of wall enhancement, which is an important marker in many inflammatory conditions. Similar to unenhanced CT, MRA without IV contrast is able to identify aneurysms, edema, perivascular stranding, gas, and disrupted calcifications that may be associated with aortic infections [50]. For suspected neoplasms, an irregular soft-tissue structure may be identified that may or may not enhance after IV contrast administration [46,47]. Radiography Chest Chest radiography may be helpful in evaluating the contour, size, and location of the thoracic aorta and the great vessels, which, if abnormal, would prompt further investigation [10,21]. Radiography is not considered an adequate modality to evaluate for inflammatory, infectious, neoplastic, or metabolic aortic diseases. Vascular duplex US can identify vascular wall thickening, which is an important marker in patients with generalized vascular inflammation [74], GCA [73,75], Behcet disease [76], and Takayasu arteritis [44]. Additionally, US is better than catheter-based angiography for detecting stenoses, occlusions, and aneurysms from Takayasu arteritis [44]. Nonetheless, it must be remembered that these evaluations primarily focused on nonaortic vessels. In fact, one study compared duplex US to FDG-PET/CT for the detection of extracranial large vessel vasculitis and found that US was only 26% sensitive for detecting aortic involvement. Other authors have also recognized the limitations of US for measuring wall thickness of the aorta [44,75]. For suspected neoplastic processes, US is of little value because it is not able to reliably differentiate between malignant and benign tissue [50]. There is no relevant literature available to examine the use of US in suspected aortic infection. | 3082597 |
acrac_3082597_7 | Nontraumatic Aortic Disease | US Echocardiography Transthoracic TTE can view the thoracic aorta (mainly the ascending aorta and, to some extent, the proximal descending aorta and arch) and the aortic valve (for presence and quantification of aortic regurgitation). There is no relevant literature supporting TTE as the initial imaging modality when evaluating infectious, inflammatory, metabolic, or neoplastic processes in the aorta. US Echocardiography Transesophageal TEE may provide views of the descending aorta not appreciated on TTE, but there is no relevant literature supporting TEE as the initial imaging modality when evaluating infectious, inflammatory, metabolic, or neoplastic processes in the aorta. Aortography Chest and Abdomen Aortography no longer has a significant role as the initial imaging modality for suspected degenerative or atherosclerotic disease of the aorta, as the availability and accuracy of noninvasive methods continues to increase. Catheter-based angiography remains a critical component of care when an intervention is planned. Nontraumatic Aortic Disease CTA Chest and Abdomen with IV Contrast CTA with IV contrast is an important tool when evaluating the aorta for suspected degenerative and atherosclerotic changes as it provides information about the aortic lumen, the aortic wall, and surrounding aortic structures [86,87]. CT can also be used to detect other pathologies in the lungs, chest wall, and pleura, which can mimic the symptoms of aortic disease [88]. The addition of a venous phase to the CTA appears to increase its ability to identify both benign and malignant incidental pathology in nonvascular structures. [89]. Electrocardiograph (ECG)-gated aortic CTA decreases pulsation artifacts of the ascending aorta, which allows for a more accurate measurement of the ascending aortic diameter and potentially increases diagnostic confidence [90]. CTA provides information about the aortic root [91], aortic valve area and function, aortic wall elasticity, and morphology in general [92,93]. | Nontraumatic Aortic Disease. US Echocardiography Transthoracic TTE can view the thoracic aorta (mainly the ascending aorta and, to some extent, the proximal descending aorta and arch) and the aortic valve (for presence and quantification of aortic regurgitation). There is no relevant literature supporting TTE as the initial imaging modality when evaluating infectious, inflammatory, metabolic, or neoplastic processes in the aorta. US Echocardiography Transesophageal TEE may provide views of the descending aorta not appreciated on TTE, but there is no relevant literature supporting TEE as the initial imaging modality when evaluating infectious, inflammatory, metabolic, or neoplastic processes in the aorta. Aortography Chest and Abdomen Aortography no longer has a significant role as the initial imaging modality for suspected degenerative or atherosclerotic disease of the aorta, as the availability and accuracy of noninvasive methods continues to increase. Catheter-based angiography remains a critical component of care when an intervention is planned. Nontraumatic Aortic Disease CTA Chest and Abdomen with IV Contrast CTA with IV contrast is an important tool when evaluating the aorta for suspected degenerative and atherosclerotic changes as it provides information about the aortic lumen, the aortic wall, and surrounding aortic structures [86,87]. CT can also be used to detect other pathologies in the lungs, chest wall, and pleura, which can mimic the symptoms of aortic disease [88]. The addition of a venous phase to the CTA appears to increase its ability to identify both benign and malignant incidental pathology in nonvascular structures. [89]. Electrocardiograph (ECG)-gated aortic CTA decreases pulsation artifacts of the ascending aorta, which allows for a more accurate measurement of the ascending aortic diameter and potentially increases diagnostic confidence [90]. CTA provides information about the aortic root [91], aortic valve area and function, aortic wall elasticity, and morphology in general [92,93]. | 3082597 |
acrac_3082597_8 | Nontraumatic Aortic Disease | The CTA 3-D data set can be postprocessed and manipulated perpendicular to the flow lumen, allowing for accurate measurements for longitudinal evaluation of aortic growth and lumen diameters as well as planning for endovascular or surgical treatment [87,94,95]. Even though the maximum diameter of the aorta is the most consistent predictor of future rupture, other CTA findings, such as luminal contrast heterogeneity, intraluminal thrombus volume, aortic wall distensibility, and aneurysm geometry, help identify patients at risk for rupture [96-98]. Geometric models from CTA examinations can be used to create computational flow dynamics, which may also be useful in identifying patients with thoracic aortic aneurysms who are at risk for rupture [99]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature for the use of FDG-PET/CT imaging as an initial evaluation of degenerative or atherosclerotic aortic diseases. MRA Chest and Abdomen Similar to MRA without IV contrast, MRA without and with IV contrast can be used to obtain hemodynamic information about aortic aneurysms from computational flow dynamics or 4-D flow MRI [99]. The addition of IV contrast improves visualization of the aorta and great vessels and decreases overall acquisition time [100-104]. However, there is no definitive evidence that the addition of IV contrast improves the overall accuracy of MRA for degenerative aortic diseases. MRI without IV contrast using double-inversion recovery T1-weighted imaging and balanced steady-state free- precession MRA allows for imaging of the aorta, especially when acquisition is ECG-gated [105]. The accuracy of balanced steady-state free-precession MRA is close to 100% for detecting thoracic aortic aneurysm, dissection, intramural hematoma, and penetrating aortic ulcer when measured against the reference standard of MRA with IV contrast material [101,106]. It can be used to evaluate the entire thoracic aorta and its branches [107]. | Nontraumatic Aortic Disease. The CTA 3-D data set can be postprocessed and manipulated perpendicular to the flow lumen, allowing for accurate measurements for longitudinal evaluation of aortic growth and lumen diameters as well as planning for endovascular or surgical treatment [87,94,95]. Even though the maximum diameter of the aorta is the most consistent predictor of future rupture, other CTA findings, such as luminal contrast heterogeneity, intraluminal thrombus volume, aortic wall distensibility, and aneurysm geometry, help identify patients at risk for rupture [96-98]. Geometric models from CTA examinations can be used to create computational flow dynamics, which may also be useful in identifying patients with thoracic aortic aneurysms who are at risk for rupture [99]. FDG-PET/CT Skull Base to Mid-Thigh There is no relevant literature for the use of FDG-PET/CT imaging as an initial evaluation of degenerative or atherosclerotic aortic diseases. MRA Chest and Abdomen Similar to MRA without IV contrast, MRA without and with IV contrast can be used to obtain hemodynamic information about aortic aneurysms from computational flow dynamics or 4-D flow MRI [99]. The addition of IV contrast improves visualization of the aorta and great vessels and decreases overall acquisition time [100-104]. However, there is no definitive evidence that the addition of IV contrast improves the overall accuracy of MRA for degenerative aortic diseases. MRI without IV contrast using double-inversion recovery T1-weighted imaging and balanced steady-state free- precession MRA allows for imaging of the aorta, especially when acquisition is ECG-gated [105]. The accuracy of balanced steady-state free-precession MRA is close to 100% for detecting thoracic aortic aneurysm, dissection, intramural hematoma, and penetrating aortic ulcer when measured against the reference standard of MRA with IV contrast material [101,106]. It can be used to evaluate the entire thoracic aorta and its branches [107]. | 3082597 |
acrac_3082597_9 | Nontraumatic Aortic Disease | MRA without IV contrast can also be used to create geometric models for computational flow dynamics [99]. Additionally, 4-D flow MRI sequences can be obtained [99]. These sequences are the acquisition of 3-D phase-contrast images in a time-resolved, ECG-gated manner with 3-D velocity encoding. Both computational flow dynamics and 4-D flow MRI can be used to examine hemodynamic information in thoracic aortic aneurysms, such as wall shear stress, flow patterns, and helical flow that may help to identify patients at risk for rupture [99]. For aortic atherosclerotic disease, both MRA without IV contrast and MRA without and with IV contrast can be used to collect physiologic information about aortic flow in order to provide an assessment of aortic wall stiffness and to generate 4-D flow MRI [42,99]. One disadvantage of MRI of the chest and abdomen without and with IV is that it may underestimate the thickness of atherosclerotic plaques compared with other modalities [108]. One advantage of MRI of the chest and abdomen is that it can be used to evaluate the composition of atherosclerotic plaques for lipids, fibrosis, calcifications, and intraplaque hemorrhage [95,109]. Because of improved visualization and decreased acquisition times, the use of IV contrast for MRA of the chest and abdomen is preferred, but sufficient information can also be obtained without the use of IV contrast [100-104,110]. Radiography Chest The chest radiograph is a helpful initial imaging evaluation for the diagnosis of degenerative aortic disease, especially if an acute complication is suspected. However, because of the lack of sensitivity in assessing the extent of disease [35], more definitive tests are required. Regarding atherosclerotic aortic disease, some studies have used lateral lumbar radiographs to both quantify and correlate atherosclerotic disease in the aorta to bone mineral density Nontraumatic Aortic Disease [111], patient diet [112], and more generalized atherosclerotic disease [113]. | Nontraumatic Aortic Disease. MRA without IV contrast can also be used to create geometric models for computational flow dynamics [99]. Additionally, 4-D flow MRI sequences can be obtained [99]. These sequences are the acquisition of 3-D phase-contrast images in a time-resolved, ECG-gated manner with 3-D velocity encoding. Both computational flow dynamics and 4-D flow MRI can be used to examine hemodynamic information in thoracic aortic aneurysms, such as wall shear stress, flow patterns, and helical flow that may help to identify patients at risk for rupture [99]. For aortic atherosclerotic disease, both MRA without IV contrast and MRA without and with IV contrast can be used to collect physiologic information about aortic flow in order to provide an assessment of aortic wall stiffness and to generate 4-D flow MRI [42,99]. One disadvantage of MRI of the chest and abdomen without and with IV is that it may underestimate the thickness of atherosclerotic plaques compared with other modalities [108]. One advantage of MRI of the chest and abdomen is that it can be used to evaluate the composition of atherosclerotic plaques for lipids, fibrosis, calcifications, and intraplaque hemorrhage [95,109]. Because of improved visualization and decreased acquisition times, the use of IV contrast for MRA of the chest and abdomen is preferred, but sufficient information can also be obtained without the use of IV contrast [100-104,110]. Radiography Chest The chest radiograph is a helpful initial imaging evaluation for the diagnosis of degenerative aortic disease, especially if an acute complication is suspected. However, because of the lack of sensitivity in assessing the extent of disease [35], more definitive tests are required. Regarding atherosclerotic aortic disease, some studies have used lateral lumbar radiographs to both quantify and correlate atherosclerotic disease in the aorta to bone mineral density Nontraumatic Aortic Disease [111], patient diet [112], and more generalized atherosclerotic disease [113]. | 3082597 |
acrac_69468_0 | Acute Pancreatitis | Introduction/Background Acute pancreatitis (AP), an inflammatory process affecting the pancreas, is the third most frequent gastrointestinal cause of hospital admissions in the United States [1]. AP results in approximately 300,000 hospital admissions each year, with associated costs of approximately $2.6 billion [1,2]. The incidence of AP is increasing and is estimated at 40 per 100,000 people. The clinical diagnosis of AP requires 2 of the following 3 features: 1) abdominal pain consistent with AP (acute onset of persistent, severe, epigastric pain often radiating to the back); 2) serum lipase or amylase levels at least 3 times the upper limits of normal; and 3) characteristic findings of AP on contrast-enhanced CT, MRI, or transabdominal ultrasound (US) [3]. As such, if the abdominal pain is characteristic of pancreatitis and the amylase or lipase levels are not elevated to at least 3 times above normal, imaging is required for diagnosis. Imaging is also performed in AP to investigate the etiology, complications, and extent of disease. Imaging AP requires an understanding of the disease subtypes, evolution, and associated complications. Familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, modified by the Acute Pancreatitis Classification Working Group in 2008 is also essential [3]. Special Imaging Considerations Radiographs Conventional radiographs and upper gastrointestinal series currently have a limited role in the evaluation of a patient with AP. Radiographic signs of AP, such as dilated air-filled duodenum or jejunum, are secondary and nonspecific. Similarly, thickened rugal or duodenal folds or dilation of the duodenal C-loop are nonspecific findings of AP seen on upper gastrointestinal series or follow-through studies. | Acute Pancreatitis. Introduction/Background Acute pancreatitis (AP), an inflammatory process affecting the pancreas, is the third most frequent gastrointestinal cause of hospital admissions in the United States [1]. AP results in approximately 300,000 hospital admissions each year, with associated costs of approximately $2.6 billion [1,2]. The incidence of AP is increasing and is estimated at 40 per 100,000 people. The clinical diagnosis of AP requires 2 of the following 3 features: 1) abdominal pain consistent with AP (acute onset of persistent, severe, epigastric pain often radiating to the back); 2) serum lipase or amylase levels at least 3 times the upper limits of normal; and 3) characteristic findings of AP on contrast-enhanced CT, MRI, or transabdominal ultrasound (US) [3]. As such, if the abdominal pain is characteristic of pancreatitis and the amylase or lipase levels are not elevated to at least 3 times above normal, imaging is required for diagnosis. Imaging is also performed in AP to investigate the etiology, complications, and extent of disease. Imaging AP requires an understanding of the disease subtypes, evolution, and associated complications. Familiarity with the appropriate radiologic nomenclature as defined by the Atlanta symposium in 1992 and, more recently, modified by the Acute Pancreatitis Classification Working Group in 2008 is also essential [3]. Special Imaging Considerations Radiographs Conventional radiographs and upper gastrointestinal series currently have a limited role in the evaluation of a patient with AP. Radiographic signs of AP, such as dilated air-filled duodenum or jejunum, are secondary and nonspecific. Similarly, thickened rugal or duodenal folds or dilation of the duodenal C-loop are nonspecific findings of AP seen on upper gastrointestinal series or follow-through studies. | 69468 |
acrac_69468_1 | Acute Pancreatitis | Occasionally, radiographs may be useful when obtained for evaluation of nonspecific abdominal pain, as one can quickly assess for the presence of bowel obstruction or calcified gallstones in the gallbladder or common bile duct. Radiographs can also be useful for evaluating the presence of biliary or pancreatic duct stents. aUniversity of Alabama Medical Center, Birmingham, Alabama. bJohns Hopkins Hospital, Baltimore, Maryland. cPanel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. dPanel Vice-Chair, Northwestern University, Chicago, Illinois. eUniversity of Arizona, Banner University Medical Center, Tucson, Arizona. fGlobal Advanced Imaging, PLLC, Little Rock, Arkansas. gDuke University Medical Center, Durham, North Carolina. hThe University of South Florida Morsani College of Medicine, Tampa, Florida. iUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. jMontefiore Medical Center, Bronx, New York. kUMass Memorial Medical Center, Worcester, Massachusetts. lUniversity of Florida College of Medicine, Gainesville, Florida. mRush University Medical Center, Chicago, Illinois; American College of Surgeons. nNew York University Medical Center, New York, New York. oStanford University Medical Center, Stanford, California. pUniversity of Alabama Medical Center, Birmingham, Alabama. qSpecialty 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 society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. Reprint requests to: [email protected] | Acute Pancreatitis. Occasionally, radiographs may be useful when obtained for evaluation of nonspecific abdominal pain, as one can quickly assess for the presence of bowel obstruction or calcified gallstones in the gallbladder or common bile duct. Radiographs can also be useful for evaluating the presence of biliary or pancreatic duct stents. aUniversity of Alabama Medical Center, Birmingham, Alabama. bJohns Hopkins Hospital, Baltimore, Maryland. cPanel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland. dPanel Vice-Chair, Northwestern University, Chicago, Illinois. eUniversity of Arizona, Banner University Medical Center, Tucson, Arizona. fGlobal Advanced Imaging, PLLC, Little Rock, Arkansas. gDuke University Medical Center, Durham, North Carolina. hThe University of South Florida Morsani College of Medicine, Tampa, Florida. iUniversity of Texas Health Science Center at Houston and McGovern Medical School, Houston, Texas; American Gastroenterological Association. jMontefiore Medical Center, Bronx, New York. kUMass Memorial Medical Center, Worcester, Massachusetts. lUniversity of Florida College of Medicine, Gainesville, Florida. mRush University Medical Center, Chicago, Illinois; American College of Surgeons. nNew York University Medical Center, New York, New York. oStanford University Medical Center, Stanford, California. pUniversity of Alabama Medical Center, Birmingham, Alabama. qSpecialty 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 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] | 69468 |
acrac_69468_2 | Acute Pancreatitis | Acute Pancreatitis for evaluation of gallstones and it is nondiagnostic, possibly because of obesity, gas, etc, and an MRI could not be performed. Patients with acute biliary pancreatitis may undergo early ERCP for removal of stones causing common bile duct obstruction to reduce disease severity and risk of complications [9,10]. The appropriate timing of ERCP is controversial [9,11]. Some authors argue that if ERCP has to be performed in patients with gallstone-related AP, it should be performed within 72 hours to have the highest chance of mitigating the pancreatic inflammatory process and reducing systemic complications [10]. However, the majority of patients with gallstone pancreatitis suffer from transient obstruction with spontaneous resolution [9]. Approximately half of the patients with cholestatic liver biochemistry and a dilated common bile duct on US or CT did not have a common bile duct stone detected during ERCP [10]. Because ERCP is an invasive procedure that can sometimes lead to complications, including perforation and hemorrhage, accurately identifying those patients with choledocholithiasis who are most likely to benefit from early therapeutic ERCP is important. MRCP images of the biliary system are more sensitive and specific than US for the detection of choledocholithiasis [9,12]. MRCP has a high concordance rate with ERCP for the detection of biliary origin of AP [9]. As such, MRCP prior to ERCP in patients at high risk for choledocholithiasis is common, replacing diagnostic ERCP in many cases. There is conflicting evidence regarding whether the selective use of MRCP in patients at high risk for choledocholithiasis reduces hospital stay and resultant hospital charges [9,13]. MRCP has the added advantage of detecting anatomic anomalies that may contribute to the etiology of AP, such as pancreas divisum or bile duct or pancreatic duct strictures. Therefore, for the assessment of biliary pathology on MRCP, MRI without IV contrast with MRCP may serve as a problem-solving tool. | Acute Pancreatitis. Acute Pancreatitis for evaluation of gallstones and it is nondiagnostic, possibly because of obesity, gas, etc, and an MRI could not be performed. Patients with acute biliary pancreatitis may undergo early ERCP for removal of stones causing common bile duct obstruction to reduce disease severity and risk of complications [9,10]. The appropriate timing of ERCP is controversial [9,11]. Some authors argue that if ERCP has to be performed in patients with gallstone-related AP, it should be performed within 72 hours to have the highest chance of mitigating the pancreatic inflammatory process and reducing systemic complications [10]. However, the majority of patients with gallstone pancreatitis suffer from transient obstruction with spontaneous resolution [9]. Approximately half of the patients with cholestatic liver biochemistry and a dilated common bile duct on US or CT did not have a common bile duct stone detected during ERCP [10]. Because ERCP is an invasive procedure that can sometimes lead to complications, including perforation and hemorrhage, accurately identifying those patients with choledocholithiasis who are most likely to benefit from early therapeutic ERCP is important. MRCP images of the biliary system are more sensitive and specific than US for the detection of choledocholithiasis [9,12]. MRCP has a high concordance rate with ERCP for the detection of biliary origin of AP [9]. As such, MRCP prior to ERCP in patients at high risk for choledocholithiasis is common, replacing diagnostic ERCP in many cases. There is conflicting evidence regarding whether the selective use of MRCP in patients at high risk for choledocholithiasis reduces hospital stay and resultant hospital charges [9,13]. MRCP has the added advantage of detecting anatomic anomalies that may contribute to the etiology of AP, such as pancreas divisum or bile duct or pancreatic duct strictures. Therefore, for the assessment of biliary pathology on MRCP, MRI without IV contrast with MRCP may serve as a problem-solving tool. | 69468 |
acrac_69468_3 | Acute Pancreatitis | US Abdomen with IV Contrast Contrast-enhanced US (CEUS) is emerging as a potential option for focal evaluation of the pancreas, and it is well suited to the evaluation of perfusion with its use of intravascular contrast agents [15]. However, the use of microbubble contrast for this indication is currently not approved by the FDA, and its use would be considered off-label. Additionally, in a majority of patients, the diagnosis of AP can be made based on the clinical findings of typical abdominal pain and elevated serum lipase or amylase levels to at least 3 times the upper limits of normal or greater. Therefore, CEUS may not provide additional information in patients with an unequivocal clinical presentation and appropriately elevated amylase and lipase. Similar to grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. US Duplex Doppler Abdomen Adding spectral, color, and power Doppler US to traditional grayscale US adds hemodynamic information concerning vessel patency and flow direction and may be useful for differentiating vascular from nonvascular Acute Pancreatitis structures, particularly differentiating hepatic arteries and portal veins from bile ducts. Every patient presenting with AP and no obvious alternative etiology should undergo transabdominal US to assess for gallstones as the possible cause [12]. Spectral, color, and power Doppler should be used as necessary to differentiate vascular from nonvascular structures in this instance. However, beyond evaluating for gallstones in the large majority of patients, the diagnosis can be made based on typical clinical symptoms and laboratory findings of an amylase and/or lipase level elevated to 3 times the upper limit of normal, or greater, without additional cross-sectional imaging [1]. Variant 2: Suspected acute pancreatitis. | Acute Pancreatitis. US Abdomen with IV Contrast Contrast-enhanced US (CEUS) is emerging as a potential option for focal evaluation of the pancreas, and it is well suited to the evaluation of perfusion with its use of intravascular contrast agents [15]. However, the use of microbubble contrast for this indication is currently not approved by the FDA, and its use would be considered off-label. Additionally, in a majority of patients, the diagnosis of AP can be made based on the clinical findings of typical abdominal pain and elevated serum lipase or amylase levels to at least 3 times the upper limits of normal or greater. Therefore, CEUS may not provide additional information in patients with an unequivocal clinical presentation and appropriately elevated amylase and lipase. Similar to grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. US Duplex Doppler Abdomen Adding spectral, color, and power Doppler US to traditional grayscale US adds hemodynamic information concerning vessel patency and flow direction and may be useful for differentiating vascular from nonvascular Acute Pancreatitis structures, particularly differentiating hepatic arteries and portal veins from bile ducts. Every patient presenting with AP and no obvious alternative etiology should undergo transabdominal US to assess for gallstones as the possible cause [12]. Spectral, color, and power Doppler should be used as necessary to differentiate vascular from nonvascular structures in this instance. However, beyond evaluating for gallstones in the large majority of patients, the diagnosis can be made based on typical clinical symptoms and laboratory findings of an amylase and/or lipase level elevated to 3 times the upper limit of normal, or greater, without additional cross-sectional imaging [1]. Variant 2: Suspected acute pancreatitis. | 69468 |
acrac_69468_4 | Acute Pancreatitis | Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). Initial imaging. CT Abdomen and Pelvis In patients with acute abdominal pain, there are often multiple potential etiologies to consider, including peptic ulcer disease, bowel perforation, and mesenteric ischemia, among others. Laboratory studies, specifically serum amylase and lipase, can help differentiate AP from these other considerations. Although serum amylase level is the most commonly used biochemical marker of AP, levels of amylase less than 3 times that of normal levels at the time of diagnosis can be related to rapid clearing. In contrast, serum lipase rises later but may be a more reliable marker of AP because of its longer half-life [16]. Additionally, significantly lower serum amylase and lipase levels have been observed in patients with alcoholic AP, perhaps as a result of poor pancreatic exocrine function [14]. Elevated triglyceride levels are also known to interfere with the serum amylase assay; conversely, both amylase and lipase may be elevated in patients with renal insufficiency without AP [16]. CT abdomen and pelvis without IV contrast can help in making the diagnosis of AP by assessing the presence of peripancreatic stranding and fluid collections. However, stratification of disease severity cannot be performed because of the lack of assessment of pancreatic necrosis. Given the limitations of early CT with or without IV contrast for stratification of disease severity, performing both CT abdomen and pelvis without and with IV contrast does not add to the diagnosis of AP, and CT abdomen and pelvis with IV contrast is preferred to exclude other etiologies of abdominal pain. | Acute Pancreatitis. Initial presentation with atypical signs and symptoms; including equivocal amylase and lipase values (possibly confounded by acute kidney injury or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). Initial imaging. CT Abdomen and Pelvis In patients with acute abdominal pain, there are often multiple potential etiologies to consider, including peptic ulcer disease, bowel perforation, and mesenteric ischemia, among others. Laboratory studies, specifically serum amylase and lipase, can help differentiate AP from these other considerations. Although serum amylase level is the most commonly used biochemical marker of AP, levels of amylase less than 3 times that of normal levels at the time of diagnosis can be related to rapid clearing. In contrast, serum lipase rises later but may be a more reliable marker of AP because of its longer half-life [16]. Additionally, significantly lower serum amylase and lipase levels have been observed in patients with alcoholic AP, perhaps as a result of poor pancreatic exocrine function [14]. Elevated triglyceride levels are also known to interfere with the serum amylase assay; conversely, both amylase and lipase may be elevated in patients with renal insufficiency without AP [16]. CT abdomen and pelvis without IV contrast can help in making the diagnosis of AP by assessing the presence of peripancreatic stranding and fluid collections. However, stratification of disease severity cannot be performed because of the lack of assessment of pancreatic necrosis. Given the limitations of early CT with or without IV contrast for stratification of disease severity, performing both CT abdomen and pelvis without and with IV contrast does not add to the diagnosis of AP, and CT abdomen and pelvis with IV contrast is preferred to exclude other etiologies of abdominal pain. | 69468 |
acrac_69468_5 | Acute Pancreatitis | Limitations of CT include relatively poor sensitivity for identifying ductal abnormalities, detecting subtle pancreatic parenchymal changes, and identifying noncalcified gallstones and choledocholithiasis. MRI Abdomen For meeting the imaging diagnostic criteria for AP, MRI abdomen without and with IV contrast with MRCP is at least equal and arguably superior to CT, particularly given the higher soft-tissue contrast resolution. Limitations of MRI include greater frequency of motion-related artifacts and a longer imaging time compared with that of CT. This is an important consideration in an acutely ill patient in whom the study may be degraded by large-volume ascites and breathing-related artifacts, especially in the presence of abdominal pain and pleural effusions. Benefits include good sensitivity even without the administration of an IV contrast agent (making it a useful alternative for patients with renal impairment or allergy to iodine-based CT contrast agents). Although MRI without IV contrast with MRCP provides information about the presence of biliary stones and fluid collections, pancreatic necrosis cannot be accurately assessed in the absence of IV contrast. Acute Pancreatitis The MRI findings of AP are typically an enlarged, edematous gland that is low signal on T1-weighted images and high signal on T2-weighted images. MRI can detect trace amounts of peripancreatic fluid, which is high signal on T2-weighted images and offers higher sensitivity than CT for the diagnosis of subtle, early changes of AP [17,18]. MRI is particularly well suited for pregnant women, patients with renal compromise, and younger patients with suspected AP, especially since studies have shown that patients who undergo early CT for AP are more likely to have repeat CT scans during the same admission [6,8]. | Acute Pancreatitis. Limitations of CT include relatively poor sensitivity for identifying ductal abnormalities, detecting subtle pancreatic parenchymal changes, and identifying noncalcified gallstones and choledocholithiasis. MRI Abdomen For meeting the imaging diagnostic criteria for AP, MRI abdomen without and with IV contrast with MRCP is at least equal and arguably superior to CT, particularly given the higher soft-tissue contrast resolution. Limitations of MRI include greater frequency of motion-related artifacts and a longer imaging time compared with that of CT. This is an important consideration in an acutely ill patient in whom the study may be degraded by large-volume ascites and breathing-related artifacts, especially in the presence of abdominal pain and pleural effusions. Benefits include good sensitivity even without the administration of an IV contrast agent (making it a useful alternative for patients with renal impairment or allergy to iodine-based CT contrast agents). Although MRI without IV contrast with MRCP provides information about the presence of biliary stones and fluid collections, pancreatic necrosis cannot be accurately assessed in the absence of IV contrast. Acute Pancreatitis The MRI findings of AP are typically an enlarged, edematous gland that is low signal on T1-weighted images and high signal on T2-weighted images. MRI can detect trace amounts of peripancreatic fluid, which is high signal on T2-weighted images and offers higher sensitivity than CT for the diagnosis of subtle, early changes of AP [17,18]. MRI is particularly well suited for pregnant women, patients with renal compromise, and younger patients with suspected AP, especially since studies have shown that patients who undergo early CT for AP are more likely to have repeat CT scans during the same admission [6,8]. | 69468 |
acrac_69468_6 | Acute Pancreatitis | MRI has an added advantage for noninvasive evaluation of the pancreatic parenchyma, biliary and pancreatic ducts, adjacent soft tissues, vascular structures, and composition of AP-associated fluid collections in a single examination [17,19,20]. However, MRI abdomen without and with IV contrast with MRCP does not provide coverage and adequate evaluation of the bowel to assess an alternative diagnosis of bowel ischemia, perforation, etc. US Abdomen US is often the first-line imaging modality in most centers for the evaluation of acute abdominal pain because it is reproducible and can be accomplished at the bedside [15]. Approximately 20% of the time, the pancreas demonstrates features of AP on US, including diffuse glandular enlargement, hypoechoic echotexture of the pancreas consistent with edema, and ascites. US can also be useful for the diagnosis of an alternative etiology of abdominal pain, such as acute cholecystitis. However, US is limited by overlying bowel gas or adynamic ileus in the majority of patients with AP [15]. The primary use of US in patients with AP is to identify gallstones or biliary ductal dilatation. US Abdomen with IV Contrast CEUS is emerging as a potential option for focal evaluation of the pancreas, and it is well suited to the evaluation of perfusion with its use of intravascular contrast agents [15]. However, the use of microbubble contrast for this indication is currently not approved by the FDA, so its use would be considered off-label. Furthermore, CEUS is a focused examination, and in patients with an equivocal presentation of pancreatitis for whom diagnoses other than pancreatitis may be possible, a focused examination may be inadequate. Finally, similar to grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. Acute Pancreatitis Even in cases of severe AP, clinical scoring methods are used to direct patient care independent of imaging in the early phase. | Acute Pancreatitis. MRI has an added advantage for noninvasive evaluation of the pancreatic parenchyma, biliary and pancreatic ducts, adjacent soft tissues, vascular structures, and composition of AP-associated fluid collections in a single examination [17,19,20]. However, MRI abdomen without and with IV contrast with MRCP does not provide coverage and adequate evaluation of the bowel to assess an alternative diagnosis of bowel ischemia, perforation, etc. US Abdomen US is often the first-line imaging modality in most centers for the evaluation of acute abdominal pain because it is reproducible and can be accomplished at the bedside [15]. Approximately 20% of the time, the pancreas demonstrates features of AP on US, including diffuse glandular enlargement, hypoechoic echotexture of the pancreas consistent with edema, and ascites. US can also be useful for the diagnosis of an alternative etiology of abdominal pain, such as acute cholecystitis. However, US is limited by overlying bowel gas or adynamic ileus in the majority of patients with AP [15]. The primary use of US in patients with AP is to identify gallstones or biliary ductal dilatation. US Abdomen with IV Contrast CEUS is emerging as a potential option for focal evaluation of the pancreas, and it is well suited to the evaluation of perfusion with its use of intravascular contrast agents [15]. However, the use of microbubble contrast for this indication is currently not approved by the FDA, so its use would be considered off-label. Furthermore, CEUS is a focused examination, and in patients with an equivocal presentation of pancreatitis for whom diagnoses other than pancreatitis may be possible, a focused examination may be inadequate. Finally, similar to grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. Acute Pancreatitis Even in cases of severe AP, clinical scoring methods are used to direct patient care independent of imaging in the early phase. | 69468 |
acrac_69468_7 | Acute Pancreatitis | Frequently used clinical scoring methods include the Ranson, Acute Physiology, Age, and Chronic Health Evaluation (APACHE)-II, Marshall, and the Bedside Index for Severity in AP (BISAP). Imaging is generally not necessary to document local complications in the early phase. This is because, even though pancreatic necrosis is a well-established risk factor for morbidity and mortality, the presence and extent of pancreatic and peripancreatic necrosis may not be reliably demonstrated on imaging before 5 to 7 days into the clinical course because both necrotic and edematous pancreatic parenchyma show heterogeneous enhancement. In addition, the extent of morphologic changes seen on imaging does not correlate well with the severity of organ failure [3]. Furthermore, even if imaging identifies the presence of fluid collections or pancreatic necrosis in the first week, typically no interventions for these complications are pursued in the early phase [3,18]. CT Abdomen and Pelvis Although it is generally not necessary to document local complications in the early phase with imaging, CT abdomen and pelvis with IV contrast is the primary imaging modality used in the assessment of a critically ill patient, particularly if cross-sectional imaging was not obtained earlier in the clinical course for AP diagnosis. CT abdomen and pelvis with IV contrast has shown consistent clinical value in predicting disease severity and outcomes in AP. The CT severity index is an imaging prognosticator based on the combined assessment of peripancreatic fluid collections and the degree of pancreatic necrosis. A higher CT severity index score is associated with increased morbidity and mortality. A modified CT severity index includes extrapancreatic complications (such as ascites) and vascular complications in the grading system. By including these additional factors, the modified CT severity index has a stronger correlation with patient outcome [2]. | Acute Pancreatitis. Frequently used clinical scoring methods include the Ranson, Acute Physiology, Age, and Chronic Health Evaluation (APACHE)-II, Marshall, and the Bedside Index for Severity in AP (BISAP). Imaging is generally not necessary to document local complications in the early phase. This is because, even though pancreatic necrosis is a well-established risk factor for morbidity and mortality, the presence and extent of pancreatic and peripancreatic necrosis may not be reliably demonstrated on imaging before 5 to 7 days into the clinical course because both necrotic and edematous pancreatic parenchyma show heterogeneous enhancement. In addition, the extent of morphologic changes seen on imaging does not correlate well with the severity of organ failure [3]. Furthermore, even if imaging identifies the presence of fluid collections or pancreatic necrosis in the first week, typically no interventions for these complications are pursued in the early phase [3,18]. CT Abdomen and Pelvis Although it is generally not necessary to document local complications in the early phase with imaging, CT abdomen and pelvis with IV contrast is the primary imaging modality used in the assessment of a critically ill patient, particularly if cross-sectional imaging was not obtained earlier in the clinical course for AP diagnosis. CT abdomen and pelvis with IV contrast has shown consistent clinical value in predicting disease severity and outcomes in AP. The CT severity index is an imaging prognosticator based on the combined assessment of peripancreatic fluid collections and the degree of pancreatic necrosis. A higher CT severity index score is associated with increased morbidity and mortality. A modified CT severity index includes extrapancreatic complications (such as ascites) and vascular complications in the grading system. By including these additional factors, the modified CT severity index has a stronger correlation with patient outcome [2]. | 69468 |
acrac_69468_8 | Acute Pancreatitis | CT abdomen and pelvis with IV contrast to evaluate for pancreatic necrosis, is more reliable when performed 5 to 7 days after presentation, as impaired pancreatic perfusion, edema, and pancreatic necrosis evolve over several days and earlier imaging may underestimate necrosis [2,3]. Similarly, CT abdomen and pelvis with IV contrast is also frequently used for the evaluation of acute peripancreatic fluid collections. Most fluid collections develop in the early phase of pancreatitis and approximately half spontaneously resolve. These acute peripancreatic collections do not have a solid component or a discrete wall and are usually found in the lesser sac and anterior pararenal space. They are usually sterile, rarely become infected, and do not typically necessitate early (if any) intervention [18,21]. Moreover, because patients who undergo early CT for AP are more likely to have repeat CT scans during the same admission [6,8], waiting 5 to 7 days to evaluate the severity and complications of AP with CT abdomen and pelvis with IV contrast is recommended, even in patients with suspected severe AP. In the presence of suspicion for severe disease, the utility of CT abdomen and pelvis without IV contrast is limited to the detection of fluid collections as it cannot assess the presence of pancreatic necrosis. Similarly, adding a noncontrast phase by performing CT abdomen and pelvis without and with IV contrast does not add additional diagnostic information. In a severely ill patient who may not be able to stay still through a fairly long MRI without and with IV contrast with MRCP, an MRI without IV contrast with MRCP may be performed, as a motion-degraded MRI may not add additional diagnostic value. An MRI abdomen without IV contrast with MRCP could detect the presence of pancreatic necrosis. Diffusion-weighted imaging may be used as an alternative to contrast to assess the presence of necrotizing pancreatitis in some cases. | Acute Pancreatitis. CT abdomen and pelvis with IV contrast to evaluate for pancreatic necrosis, is more reliable when performed 5 to 7 days after presentation, as impaired pancreatic perfusion, edema, and pancreatic necrosis evolve over several days and earlier imaging may underestimate necrosis [2,3]. Similarly, CT abdomen and pelvis with IV contrast is also frequently used for the evaluation of acute peripancreatic fluid collections. Most fluid collections develop in the early phase of pancreatitis and approximately half spontaneously resolve. These acute peripancreatic collections do not have a solid component or a discrete wall and are usually found in the lesser sac and anterior pararenal space. They are usually sterile, rarely become infected, and do not typically necessitate early (if any) intervention [18,21]. Moreover, because patients who undergo early CT for AP are more likely to have repeat CT scans during the same admission [6,8], waiting 5 to 7 days to evaluate the severity and complications of AP with CT abdomen and pelvis with IV contrast is recommended, even in patients with suspected severe AP. In the presence of suspicion for severe disease, the utility of CT abdomen and pelvis without IV contrast is limited to the detection of fluid collections as it cannot assess the presence of pancreatic necrosis. Similarly, adding a noncontrast phase by performing CT abdomen and pelvis without and with IV contrast does not add additional diagnostic information. In a severely ill patient who may not be able to stay still through a fairly long MRI without and with IV contrast with MRCP, an MRI without IV contrast with MRCP may be performed, as a motion-degraded MRI may not add additional diagnostic value. An MRI abdomen without IV contrast with MRCP could detect the presence of pancreatic necrosis. Diffusion-weighted imaging may be used as an alternative to contrast to assess the presence of necrotizing pancreatitis in some cases. | 69468 |
acrac_69468_9 | Acute Pancreatitis | Additionally, MRCP can assist in the diagnosis of delayed passage of choledocholithiasis, potentially avoiding unnecessary ERCP [11]. Acute Pancreatitis US Abdomen Traditional grayscale and color Doppler US is limited in the assessment of AP disease severity, as it cannot reliably distinguish interstitial from necrotizing pancreatitis because it does not allow for the assessment of parenchymal perfusion. US Abdomen with IV Contrast CEUS is emerging as a potential option for focal evaluation of the pancreas, and it is well suited to the evaluation of pancreatic perfusion with its use of intravascular contrast agents [15]. US severity indexes based on CEUS have shown a strong correlation with CT severity index and can be used in its place. Like CT, CEUS evaluation in the acute setting is limited by impaired pancreatic perfusion, edema, and the evolution of pancreatic necrosis over several days. Too-early imaging may underestimate necrosis. As with grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. US Duplex Doppler Abdomen Color Doppler US is limited in the assessment of AP disease severity because of its inability to reliably assess parenchymal perfusion. Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms. The late phase of AP occurs after the first week and is characterized by local complications, including infection and fluid collections and persistent SIRS [2,3,18]. Mild disease resolves within the first week, so the late phase only applies to patients with moderately severe or severe pancreatitis. Organ failure is likely in the setting of persistent SIRS, and persistent organ failure defines severe AP. | Acute Pancreatitis. Additionally, MRCP can assist in the diagnosis of delayed passage of choledocholithiasis, potentially avoiding unnecessary ERCP [11]. Acute Pancreatitis US Abdomen Traditional grayscale and color Doppler US is limited in the assessment of AP disease severity, as it cannot reliably distinguish interstitial from necrotizing pancreatitis because it does not allow for the assessment of parenchymal perfusion. US Abdomen with IV Contrast CEUS is emerging as a potential option for focal evaluation of the pancreas, and it is well suited to the evaluation of pancreatic perfusion with its use of intravascular contrast agents [15]. US severity indexes based on CEUS have shown a strong correlation with CT severity index and can be used in its place. Like CT, CEUS evaluation in the acute setting is limited by impaired pancreatic perfusion, edema, and the evolution of pancreatic necrosis over several days. Too-early imaging may underestimate necrosis. As with grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. US Duplex Doppler Abdomen Color Doppler US is limited in the assessment of AP disease severity because of its inability to reliably assess parenchymal perfusion. Variant 4: Acute pancreatitis. Continued SIRS, severe clinical scores, leukocytosis, and fever. Greater than 7 to 21 days after onset of symptoms. The late phase of AP occurs after the first week and is characterized by local complications, including infection and fluid collections and persistent SIRS [2,3,18]. Mild disease resolves within the first week, so the late phase only applies to patients with moderately severe or severe pancreatitis. Organ failure is likely in the setting of persistent SIRS, and persistent organ failure defines severe AP. | 69468 |
acrac_69468_10 | Acute Pancreatitis | Persistent organ failure continues to be the main determinant of severity in the late phase; however, local and systemic complications have important implications for management and are characterized by imaging. Imaging plays a major role in the late phase for assessing severity (including identifying the presence and extent of necrotizing pancreatitis and its complications), guiding interventional, endoscopic, or surgical treatment, and monitoring treatment response. Although leukocytosis and fever are clinical hallmarks of infection, imaging is also important for the evaluation of superimposed infection. It is imperative to identify superimposed infection, as the presence of infection within areas of necrosis is associated with an extremely high mortality [3]. The presence and extent of pancreatic and peripancreatic necrosis increases the likelihood of infection and infection within areas of pancreatic necrosis portends an increased risk of death, which is exacerbated by persistent organ failure. By comparison, infected necrosis without persistent organ failure has a lower mortality rate than infected necrosis with persistent organ failure [3,21]. In the absence of infection, patients with peripancreatic (extrapancreatic) necrosis without concomitant pancreatic parenchymal necrosis have a better prognosis than patients with pancreatic parenchymal necrosis. It has been suggested that, given the improved prognosis, extrapancreatic necrosis should be considered a separate clinical entity in AP [25]. In the presence of infection; however, the rates of complication and mortality for patients with only extrapancreatic necrosis are similar to those for patients with pancreatic parenchymal necrosis with or without extrapancreatic necrosis [25]. | Acute Pancreatitis. Persistent organ failure continues to be the main determinant of severity in the late phase; however, local and systemic complications have important implications for management and are characterized by imaging. Imaging plays a major role in the late phase for assessing severity (including identifying the presence and extent of necrotizing pancreatitis and its complications), guiding interventional, endoscopic, or surgical treatment, and monitoring treatment response. Although leukocytosis and fever are clinical hallmarks of infection, imaging is also important for the evaluation of superimposed infection. It is imperative to identify superimposed infection, as the presence of infection within areas of necrosis is associated with an extremely high mortality [3]. The presence and extent of pancreatic and peripancreatic necrosis increases the likelihood of infection and infection within areas of pancreatic necrosis portends an increased risk of death, which is exacerbated by persistent organ failure. By comparison, infected necrosis without persistent organ failure has a lower mortality rate than infected necrosis with persistent organ failure [3,21]. In the absence of infection, patients with peripancreatic (extrapancreatic) necrosis without concomitant pancreatic parenchymal necrosis have a better prognosis than patients with pancreatic parenchymal necrosis. It has been suggested that, given the improved prognosis, extrapancreatic necrosis should be considered a separate clinical entity in AP [25]. In the presence of infection; however, the rates of complication and mortality for patients with only extrapancreatic necrosis are similar to those for patients with pancreatic parenchymal necrosis with or without extrapancreatic necrosis [25]. | 69468 |
acrac_69468_11 | Acute Pancreatitis | In the late phase (after the first week) of moderately severe or severe pancreatitis, local complications fully develop, and it is important to characterize these complications, as they may require different interventions to avoid increased morbidity or mortality. Imaging plays a major role in identifying the presence and extent of pancreatic and peripancreatic necrosis and characterizing local complications in the late phase. CT Abdomen and Pelvis In the acute phase, it may not be possible to differentiate an acute peripancreatic fluid collection from an acute necrotic collection, as they both appear as fluid density on CT. However, after the first week in the late phase, it is easier to distinguish whether a collection is associated with pancreatic or peripancreatic necrosis. Pancreatic necrosis on CT abdomen and pelvis with IV contrast is characterized by single or multiple areas of nonenhancing pancreatic parenchyma, whereas peripancreatic fat necrosis usually appears as a low attenuation collection. False- positive results for pancreatic necrosis using enhancement on CT are due to reversible reduced perfusion and edema or fluid in the pancreatic parenchyma [21]. Infected pancreatic necrosis usually arises in the second to third week, and signs of infection on CT include gas within areas of necrosis or fluid collections. Acute Pancreatitis CT abdomen and pelvis with IV contrast is the most commonly obtained imaging test to detect the presence of peripancreatic collections [26]. Acute peripancreatic fluid collections do not have a solid component and have a density of 0 to 30 HU on CT. They also lack a discrete wall, are usually sterile, and rarely become infected. Although the majority of acute peripancreatic fluid collections are peripancreatic in the lesser sac or anterior pararenal space, some may track down into the pelvis or superiorly into the mediastinum. Therefore, CT of both the abdomen and pelvis may be warranted. | Acute Pancreatitis. In the late phase (after the first week) of moderately severe or severe pancreatitis, local complications fully develop, and it is important to characterize these complications, as they may require different interventions to avoid increased morbidity or mortality. Imaging plays a major role in identifying the presence and extent of pancreatic and peripancreatic necrosis and characterizing local complications in the late phase. CT Abdomen and Pelvis In the acute phase, it may not be possible to differentiate an acute peripancreatic fluid collection from an acute necrotic collection, as they both appear as fluid density on CT. However, after the first week in the late phase, it is easier to distinguish whether a collection is associated with pancreatic or peripancreatic necrosis. Pancreatic necrosis on CT abdomen and pelvis with IV contrast is characterized by single or multiple areas of nonenhancing pancreatic parenchyma, whereas peripancreatic fat necrosis usually appears as a low attenuation collection. False- positive results for pancreatic necrosis using enhancement on CT are due to reversible reduced perfusion and edema or fluid in the pancreatic parenchyma [21]. Infected pancreatic necrosis usually arises in the second to third week, and signs of infection on CT include gas within areas of necrosis or fluid collections. Acute Pancreatitis CT abdomen and pelvis with IV contrast is the most commonly obtained imaging test to detect the presence of peripancreatic collections [26]. Acute peripancreatic fluid collections do not have a solid component and have a density of 0 to 30 HU on CT. They also lack a discrete wall, are usually sterile, and rarely become infected. Although the majority of acute peripancreatic fluid collections are peripancreatic in the lesser sac or anterior pararenal space, some may track down into the pelvis or superiorly into the mediastinum. Therefore, CT of both the abdomen and pelvis may be warranted. | 69468 |
acrac_69468_12 | Acute Pancreatitis | More than half of acute peripancreatic fluid collections resolve without intervention in the first several weeks, and intervention is rarely pursued to avoid potentially infecting a typically sterile collection. The remaining acute peripancreatic fluid collections that do not resolve become pseudocysts after 4 weeks and are characterized by a fibrous capsule. CT is the most common modality for identifying pseudocysts and their relationship to surrounding structures prior to intervention. Acute necrotic collections are associated with pancreatic or peripancreatic necrosis and contain varying amounts of fluid and necrotic material and are of varying sizes and shapes [3]. On CT, these collections have heterogeneous, varied densities (fluid, fat, and solid material) with no or an incompletely defined wall. It can be challenging to distinguish collections that contain varying amounts of fluid and necrotic debris from pure fluid containing acute peripancreatic fluid collections on CT abdomen and pelvis with IV contrast and necrotic material within collections is often overlooked. The presence of fat globules on CT is usually associated with the presence of large amounts of debris within a collection [26]. MRI and possibly US are better at demonstrating debris and necrotic material within these collections [21,26,27]. Accurate identification of necrotic debris is important for characterization; however, it is particularly important if drainage is considered, as residual, unrecognized debris after standard drainage increases the risk of infection. Acute necrotic collections may also be associated with disruption of the main pancreatic duct within the parenchymal necrosis, and CT has reduced sensitivity for identifying ductal abnormalities. CT abdomen and pelvis without IV contrast can help in the detection of fluid collections that may or may not be infected. | Acute Pancreatitis. More than half of acute peripancreatic fluid collections resolve without intervention in the first several weeks, and intervention is rarely pursued to avoid potentially infecting a typically sterile collection. The remaining acute peripancreatic fluid collections that do not resolve become pseudocysts after 4 weeks and are characterized by a fibrous capsule. CT is the most common modality for identifying pseudocysts and their relationship to surrounding structures prior to intervention. Acute necrotic collections are associated with pancreatic or peripancreatic necrosis and contain varying amounts of fluid and necrotic material and are of varying sizes and shapes [3]. On CT, these collections have heterogeneous, varied densities (fluid, fat, and solid material) with no or an incompletely defined wall. It can be challenging to distinguish collections that contain varying amounts of fluid and necrotic debris from pure fluid containing acute peripancreatic fluid collections on CT abdomen and pelvis with IV contrast and necrotic material within collections is often overlooked. The presence of fat globules on CT is usually associated with the presence of large amounts of debris within a collection [26]. MRI and possibly US are better at demonstrating debris and necrotic material within these collections [21,26,27]. Accurate identification of necrotic debris is important for characterization; however, it is particularly important if drainage is considered, as residual, unrecognized debris after standard drainage increases the risk of infection. Acute necrotic collections may also be associated with disruption of the main pancreatic duct within the parenchymal necrosis, and CT has reduced sensitivity for identifying ductal abnormalities. CT abdomen and pelvis without IV contrast can help in the detection of fluid collections that may or may not be infected. | 69468 |
acrac_69468_13 | Acute Pancreatitis | Although, it cannot assess the presence of rim enhancement, which adds to the specificity of the diagnosis of an infected collection, in the presence of clinical concern, CT abdomen and pelvis without IV contrast can help preprocedural planning. Smaller fluid collections may sometimes be difficult to distinguish from adjacent fluid-filled bowel loops. CT abdomen and pelvis without and with IV contrast does not add to the diagnostic information. MRI Abdomen MRI abdomen without and with IV contrast with MRCP is comparable to CT abdomen and pelvis with IV contrast for the diagnosis of necrotizing pancreatitis [21]. Pancreatic necrosis is identified as areas of low signal compared with the normal increased signal of the pancreas on fat-saturated T1-weighted unenhanced images and as focal regions of nonenhancement with IV contrast. On T2-weighted images, necrosis can be low signal intensity or hyperintense when liquefied. Fluid-sensitive MRI sequences, including T2-weighted imaging and MRCP, are superior to CT for depiction of necrotic debris within fluid collections [21,26], and MRI with MRCP is well suited for evaluation of pancreatic duct disruption, which most commonly occurs as a complication of necrotizing pancreatitis [22]. Necrosis (typically of the central gland) may lead to an isolated, functional, upstream pancreatic segment that is not connected to the downstream pancreatic duct. Collections resulting from continued ductal secretions from viable pancreatic parenchyma in the area of disrupted duct typically fail to spontaneously resolve. Conservative treatment strategies or drainage will most likely fail in the setting of a disconnected pancreatic duct or lead to persistent pancreatic fistula formation; therefore, early diagnosis of this condition leads to reduced morbidity and may mitigate unnecessary drainage procedures. | Acute Pancreatitis. Although, it cannot assess the presence of rim enhancement, which adds to the specificity of the diagnosis of an infected collection, in the presence of clinical concern, CT abdomen and pelvis without IV contrast can help preprocedural planning. Smaller fluid collections may sometimes be difficult to distinguish from adjacent fluid-filled bowel loops. CT abdomen and pelvis without and with IV contrast does not add to the diagnostic information. MRI Abdomen MRI abdomen without and with IV contrast with MRCP is comparable to CT abdomen and pelvis with IV contrast for the diagnosis of necrotizing pancreatitis [21]. Pancreatic necrosis is identified as areas of low signal compared with the normal increased signal of the pancreas on fat-saturated T1-weighted unenhanced images and as focal regions of nonenhancement with IV contrast. On T2-weighted images, necrosis can be low signal intensity or hyperintense when liquefied. Fluid-sensitive MRI sequences, including T2-weighted imaging and MRCP, are superior to CT for depiction of necrotic debris within fluid collections [21,26], and MRI with MRCP is well suited for evaluation of pancreatic duct disruption, which most commonly occurs as a complication of necrotizing pancreatitis [22]. Necrosis (typically of the central gland) may lead to an isolated, functional, upstream pancreatic segment that is not connected to the downstream pancreatic duct. Collections resulting from continued ductal secretions from viable pancreatic parenchyma in the area of disrupted duct typically fail to spontaneously resolve. Conservative treatment strategies or drainage will most likely fail in the setting of a disconnected pancreatic duct or lead to persistent pancreatic fistula formation; therefore, early diagnosis of this condition leads to reduced morbidity and may mitigate unnecessary drainage procedures. | 69468 |
acrac_69468_14 | Acute Pancreatitis | MRI abdomen without IV contrast with MRCP provides more definitive evaluation of the contents of peripancreatic fluid collection and pancreatic ductal integrity when compared with CT. Limitations of MRI include motion artifacts that are due to longer scan times (especially in acutely ill patients who are unable to hold still) and decreased sensitivity for the detection of gas bubbles for imaging identification of infection. US Abdomen Traditional grayscale US is limited in the assessment of necrotizing pancreatitis because it does not allow for the assessment of parenchymal perfusion. Transabdominal US is used for characterization of peripancreatic fluid collections by evaluating for internal, necrotic debris. It is particularly helpful for guiding diagnostic and Acute Pancreatitis therapeutic intervention for large pseudocysts; however, it is limited for the identification of small collections [21]. Gas bubbles within pancreatic and peripancreatic fluid collections may be seen on transabdominal US; however, CT is more commonly used for the imaging diagnosis of infection. US Abdomen with IV Contrast CEUS is emerging as a potential option for focal evaluation of the pancreas. CEUS is well suited to the evaluation of pancreatic parenchymal perfusion, given its use of intravascular contrast agents [15]. Although CEUS can also be used to evaluate complications of pancreatitis, such as splenic artery aneurysm [28], evaluation of local complications and extrapancreatic necrosis may be limited by the focal nature of this examination. Similar to grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. US Duplex Doppler Abdomen Color Doppler US may be combined with traditional grayscale US for evaluation of vascular complications, such as arterial pseudoaneurysms or thrombosis of the portal venous system. Variant 5: Known necrotizing pancreatitis. | Acute Pancreatitis. MRI abdomen without IV contrast with MRCP provides more definitive evaluation of the contents of peripancreatic fluid collection and pancreatic ductal integrity when compared with CT. Limitations of MRI include motion artifacts that are due to longer scan times (especially in acutely ill patients who are unable to hold still) and decreased sensitivity for the detection of gas bubbles for imaging identification of infection. US Abdomen Traditional grayscale US is limited in the assessment of necrotizing pancreatitis because it does not allow for the assessment of parenchymal perfusion. Transabdominal US is used for characterization of peripancreatic fluid collections by evaluating for internal, necrotic debris. It is particularly helpful for guiding diagnostic and Acute Pancreatitis therapeutic intervention for large pseudocysts; however, it is limited for the identification of small collections [21]. Gas bubbles within pancreatic and peripancreatic fluid collections may be seen on transabdominal US; however, CT is more commonly used for the imaging diagnosis of infection. US Abdomen with IV Contrast CEUS is emerging as a potential option for focal evaluation of the pancreas. CEUS is well suited to the evaluation of pancreatic parenchymal perfusion, given its use of intravascular contrast agents [15]. Although CEUS can also be used to evaluate complications of pancreatitis, such as splenic artery aneurysm [28], evaluation of local complications and extrapancreatic necrosis may be limited by the focal nature of this examination. Similar to grayscale US, CEUS is limited by bowel gas, which can be particularly problematic in patients with AP and frequently associated paralytic ileus. US Duplex Doppler Abdomen Color Doppler US may be combined with traditional grayscale US for evaluation of vascular complications, such as arterial pseudoaneurysms or thrombosis of the portal venous system. Variant 5: Known necrotizing pancreatitis. | 69468 |
acrac_69468_15 | Acute Pancreatitis | Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells. CT Abdomen and Pelvis The diagnosis of infected necrosis or fluid collection can be suspected clinically and may be confirmed by fine- needle aspiration for culture. Because aspiration introduces the risk of infection, CT abdomen and pelvis with IV contrast may be obtained when infection is suspected clinically to assess for the presence of gas within areas of necrosis or fluid collections; although, this is of limited utility for identifying early infection [29]. Extraluminal pancreatic enzymes in AP can damage adjacent blood vessels, resulting in vasculitis and pseudoaneurysm formation. An abrupt decrease in hemoglobin or hematocrit is suspicious for pseudoaneurysm rupture. Given speed of acquisition, CT abdomen and pelvis with IV contrast with both arterial and venous phase imaging is the preferred imaging modality for assessment of suspected pseudoaneurysm rupture. CT abdomen and pelvis without IV contrast may help in the detection of hemorrhage as high-density fluid without localization of an active source. Similarly, adding a noncontrast phase by performing CT abdomen and pelvis without and with IV contrast does not add additional diagnostic information. MRI Abdomen MRI is well suited for the follow-up of pancreatic collections; however, in most cases, fine-needle aspiration sampling and microbiological examination of the collection is necessary to definitively diagnose infection; although, this method is invasive and carries a risk of secondary infection. More recently, peripheral restricted diffusion on diffusion-weighted imaging and central low apparent diffusion coefficient has been demonstrated to identify the presence of infection within AP-associated collections with higher sensitivity and accuracy than gas bubbles on CT [29]. | Acute Pancreatitis. Significant deterioration in clinical status, including abrupt decrease in hemoglobin or hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells. CT Abdomen and Pelvis The diagnosis of infected necrosis or fluid collection can be suspected clinically and may be confirmed by fine- needle aspiration for culture. Because aspiration introduces the risk of infection, CT abdomen and pelvis with IV contrast may be obtained when infection is suspected clinically to assess for the presence of gas within areas of necrosis or fluid collections; although, this is of limited utility for identifying early infection [29]. Extraluminal pancreatic enzymes in AP can damage adjacent blood vessels, resulting in vasculitis and pseudoaneurysm formation. An abrupt decrease in hemoglobin or hematocrit is suspicious for pseudoaneurysm rupture. Given speed of acquisition, CT abdomen and pelvis with IV contrast with both arterial and venous phase imaging is the preferred imaging modality for assessment of suspected pseudoaneurysm rupture. CT abdomen and pelvis without IV contrast may help in the detection of hemorrhage as high-density fluid without localization of an active source. Similarly, adding a noncontrast phase by performing CT abdomen and pelvis without and with IV contrast does not add additional diagnostic information. MRI Abdomen MRI is well suited for the follow-up of pancreatic collections; however, in most cases, fine-needle aspiration sampling and microbiological examination of the collection is necessary to definitively diagnose infection; although, this method is invasive and carries a risk of secondary infection. More recently, peripheral restricted diffusion on diffusion-weighted imaging and central low apparent diffusion coefficient has been demonstrated to identify the presence of infection within AP-associated collections with higher sensitivity and accuracy than gas bubbles on CT [29]. | 69468 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.