Clinician s Guide To Ordering NeuroImaging Studies

Transcription

1 Clinician s Guide To Ordering NeuroImaging Studies MRI CT

2 South Jersey Radiology Associates The purpose of this general guide is to assist you in choosing the appropriate imaging test to best help your patient. It is organized by test name with common indications. There are special protocols for some specific indications which are also listed. General guidelines about whether or not contrast is helpful and should be ordered are also included. Please know that all patients symptoms may not fit a specific protocol, and sometimes can overlap more than one protocol. When possible, we attempt to tailor each study to the specific clinical indication. In that regard, the more details and specificity that you provide in the prescription, the better we can protocol the examination to answer the clinical question. If you do have any questions about which study to order, how to order, or whether contrast would be helpful, please do not hesitate to call one of our radiologists. We appreciate your trust and the opportunity to participate in your patient s care. South Jersey Radiology Associates

3 DO I NEED TO ORDER CONTRAST? General principles MRI If the patient s GFR is below 30, contrast should not be given The patient will need blood work for renal function studies within 3 months if there is a history of diabetes or kidney surgery and within 6 months if the patient is over 70 with no other renal risk factors. MRIs ordered with IV contrast should be ordered, WITHOUT AND WITH CONTRAST CT CTs in general should be ordered either WITHOUT CONTRAST OR WITH CONTRAST, not both, to minimize radiation *In general, all CTs should be ordered either WITHOUT CONTRAST OR WITH CONTRAST, not both. *For MRI, anyone with a history of cancer or suspected metastases, should have an MRI WITHOUT AND WITH CONTRAST. *If MRI is contraindicated, CT of the appropriate anatomy can be considered.

4 Common Examinations Choice of examinations (Specify without contrast OR without and with contrast ). Please note that this is not an all-inclusive list; if you need an imaging protocol not listed, please specify what you would like on the prescription with a detailed history and we will generate an appropriate protocol. Please do not hesitate to contact us if you have any questions. MRI CT Specify EITHER without contrast OR without and with contrast Specify EITHER without contrast OR with contrast only MRI brain Routine MRI brain Memory loss MRI brain Memory loss with 3D Neuroquant MRI brain Orbit MRI brain Internal auditory canal (IAC) MRI brain Pituitary/sella MRI brain Skull base MRI brain Multiple sclerosis MRI brain Face/Paranasal sinus MRI brain Seizure/epilepsy MRI brain Trigeminal neuralgia MRI neck CT brain CT sinus - Routine CT sinus - Landmarx/Stryker (surgical planning) CT orbits CT facial bones CT mandible CT pituitary (if MRI contraindicated) CT temporal bones/iacs CT cervical spine CT thoracic spine CT lumbar spine MRI TMJ MRI cervical spine MRI thoracic spine MRI lumbar spine MRI sacrum or MRI sacroiliac joints MRI brachial plexus MRI lumbosacral plexus CT neck CTA brain CTA brain/carotids CTA carotids CTA MRA MRA (MR Angiography) brain MRV (MR Venography) brain MRA neck/carotids CTV CTV (CT venography) brain CTV neck

5 BRAIN (see also special brain protocols, next page) MRI Brain without contrast CPT MRI brain without and with contrast CPT Acute stroke/tia Chiari malformation Dementia/memory loss (see special protocols) Dizziness Headache Hemorrhage for acute hemorrhage, can also consider CT brain without contrast Neurologic deficit Normal pressure hydrocephalus/aqueductal stenosis Trauma for acute trauma, can also consider CT brain without contrast Vision changes (if suspect a central pathology; see special protocols) Infection Meningitis Cranial neuropathy (please specify which nerves in history and see special protocols) History of cancer with suspected metastases Inflammatory conditions (e.g. history of sarcoidosis, lupus, vasculitis) CT brain without contrast CPT CT brain with contrast CPT Acute head trauma Any head/brain pathology for which MRI is contraindicated Infection/history of cancer with suspected metastases/inflammatory conditions Any head/brain pathology for which MRI is contraindicated

6 BRAIN - Special protocols for MRI Memory loss protocol - MRI brain (without contrast) CPT Dementia Memory loss Orbit protocol - MRI brain without and with contrast CPT Cranial nerve deficits (CN 2, 3, 4, 5, 6) Diplopia Orbit or periorbital mass Optic neuropathy or optic neuritis Visual changes (if suspect orbital pathology) Grave s disease (thyroid orbitopathy) Internal Auditory Canal protocol - MRI brain without and with contrast CPT Pituitary/Sella protocol - MRI brain without and with contrast CPT Tinnitus (pulsatile and nonpulsatile) Bell s palsy Hearing loss (suspected vest. schwannoma) -If suspect temporal bone pathology, CT temporal bone without contrast Tinnitus (pulsatile and nonpulsatile) Cerebellopontine angle mass Hyperprolactinemia Hypogonadism Pituitary adenoma Skull base protocol - MRI brain without and with contrast CPT Skull base mass or pathology Multiple sclerosis protocol - MRI brain without and with contrast CPT Multiple sclerosis Paranasal sinus protocol - MRI brain without and with contrast CPT Sinus tumor/mass/infection (begin with CT sinus without contrast) Cranial nerve 1 (olfactory) pathology Seizure/Epilepsy protocol - MRI brain without and with contrast CPT Seizures or epilepsy Trigeminal Neuralgia protocol - MRI brain without and with contrast CPT Atypical facial pain Trigeminal neuralgia

7 BRAIN - Special protocols for CT CT sinus without contrast (preferred over MRI) CPT CT orbit without contrast CPT CT orbit with contrast CPT CT facial bones without contrast (Includes all facial bones inc. mandible) CT facial bones with contrast (includes all facial bones inc. mandible) CPT CT TMJ without contrast CPT CT pituitary with contrast CPT CT temporal bone without contrast CPT Sinus disease; if sinus tumor/mass/aggressive infection prefer MRI Trauma, foreign body, thyroid orbitopathy, or when MRI contraindicated Orbital infection, or when MRI contraindicated Trauma Facial infection/tumor when MR contraindicated TMJ pathology to assess for bony changes If MRI contraindicated; see MRI pituitary Conductive hearing loss; cholesteatoma; inner ear prosthesis; MRI contraindication

8 NECK MRI neck without and with contrast CPT CT neck with contrast only CPT CT neck without contrast CPT Infection Mass/lump Salivary gland pathology Cancer follow up/history of cancer with suspected metastases Inflammatory conditions (e.g. history of sarcoidosis, lupus, vasculitis) Adenopathy Dysphagia/odynophagia Vocal cord paralysis Infection Mass/lump Salivary gland pathology Cancer follow up/history of cancer with suspected metastases Inflammatory conditions (e.g. history of sarcoidosis, lupus, vasculitis) Adenopathy Dysphagia/odynophagia Vocal cord paralysis Salivary gland stone or allergic to CT dye or renal dysfunction (see criteria) TMJ MRI TMJ without contrast CPT TMJ disorders MRI TMJ without and with contrast CPT TMJ disorder History of inflammatory arthropathy (e.g. rheumatoid arthritis)

9 SPINE (specify cervical, thoracic, or lumbar) MRI (C/T/L) spine without contrast Cervical CPT Thoracic CPT Lumbar CPT MRI (C/T/L) Spine without and with contrast Cervical CPT Thoracic CPT Lumbar CPT CT (C/T/L) Spine without contrast Cervical CPT Thoracic CPT Lumbar CPT MRI Lumbosacral plexus without contrast CPT MRI Lumbosacral plexus without and with contrast Neck/back pain or radiculopathy Spinal stenosis Cord compression Degenerative disease Paresthesias Sciatica Compression fracture Trauma (if MRI contraindicated, consider CT without contrast) Syrinx (follow-up) initial workup should be with contrast Spondylolisthesis/stress fracture, CT better for spondylolysis Vertebroplasty planning Multiple sclerosis Myelopathy History of prior spine surgery (thoracic or lumbar) Epidural abscess Discitis/osteomyelitis Spinal cord tumor (diagnosis and/or follow up) Infection/inflammatory processes (e.g. sarcoidosis) Syrinx (initial evaluation) Similar indications to MRI, but use if MRI contraindicated Assess bony lesions/bony anatomy/bony degenerative changes Assess post operative hardware/fusion Lumbar plexus pathology Lumbar plexus (suspected mass, infection, neuritis, hx cancer) MRI Brachial plexus without contrast CPT MRI Brachial plexus without and with contrast Brachial plexus pathology Brachial plexus (suspected mass, infection, neuritis, hx cancer)

10 VASCULAR (ANGIOGRAPHY/VENOGRAPHY) MRA of the brain without contrast CPT Aneurysm suspected or screening Follow up of untreated aneurysm Assess intracranial vasculature (CVA/TIA) MRA of the brain without and with contrast CPT Follow up of TREATED aneurysm (clipped or coiled) Suspicion for arteriovenous malformation Suspicion for dural arteriovenous fistula MRA of the neck without and with contrast CPT MRA of the neck without contrast CPT MRV of the brain without and with contrast CPT CTA of the brain with contrast CPT CTA of the brain and neck with contrast CPT 70496, CTA of the neck with contrast CPT CTV of the brain with contrast CPT Stenosis carotid or vertebral Dissection carotid or vertebral Abnormal Carotid Doppler (prefer CTA head/neck) Subclavian steal (prefer CTA head/neck) If contrast is contraindicated Dural venous sinus thrombosis Aneurysm (if MRA contraindicated); aneurysm follow up Intracranial stenoses/occlusion AVM, or arteriovenous fistula Assess vascular stenosis or occlusion Dissection Assess vascular stenosis or occlusion Dissection Dural venous sinus thrombosis