Recognizing What to Order - Neurologic Imaging

Question 1

Head trauma, with clinical findings; may include skull fracture?

Answer 1

CT head WITHOUT contrast - MRI for problem solving.

Question 2

Head trauma, penetrating?

Answer 2

CT head WITHOUT contrast.

Question 3

Head trauma, distant, with neurologic findings?

Answer 3

MRI of head WITHOUT contrast.

Question 4

Chronic headache?

Answer 4

CT or MRI head WITH and WITHOUT contrast - Yield is relatively low.

Question 5

Headache, acute, severe (worst headache of life)?

Answer 5

CT head WITHOUT contrast - Then either CTA head or MRA head WITH or WITHOUT contrast.
–> Use of CT or MRI to subject to local preference and availability.

Question 6

New headache + HIV?

Answer 6

MRI head WITHOUT contrast.

Question 7

New headache + Pregnant?

Answer 7

MRI head WITHOUT contrast.

Question 8

New headache, suspect meningitis?

Answer 8

MRI head WITHOUT contrast or CT WITHOUT contrast.

–> Use of CT or MRI subject to local preference + availability.

Question 9

CVA, new deficit,

Answer 9

CT head WITHOUT contrast - Non contrast head CT to exclude acute intracranial hemorrhage is needed prior to thrombolytic therapy.

Question 10

CVA, new deficit, >3h?

Answer 10

MRI head WITH or WITHOUT contrast, or MRA head and neck WITH or WITHOUT contrast, or CT head WITH or WITHOUT contrast, or CTA head WITH or WITHOUT contrast.
–> Use of CT and MRI subject to local preference and availability.

Question 11

SAH proven by imaging or LP?

Answer 11

Cerebral arteriography or CTA of head.

Question 12

CVA, suspected cerebral hemorrhage?

Answer 12

CT head WITHOUT contrast.

Question 13

Seizure, alcohol or drug related?

Answer 13

MRI head WITHOUT and WITH contrast - CT can be substituted if MRI not available in emergency.

Question 14

Sezure, new onset, 18-40?

Answer 14

MRI head WITHOUT and WITH contrast - CT can be substituted if MRI not available in emergency.

Question 15

Seizure, new onset, >40?

Answer 15

MRI head WITH and WITHOUT contrast - CT can be substituted if MRI not available in emergency.

Question 16

Seizure, new onset, focal neurological deficit?

Answer 16

MRI head WITHOUT and/or WITH contrast - CT can be substituted if MRI not available in emergency.

Question 17

Low back pain, low velocity trauma, osteoporosis?

Answer 17

MRI lumbar spine WITHOUT contrast - Lumbar spine radiographs will still likely be done first.

Question 18

Low back pain, malignancy, or infection?

Answer 18

MRI lumbar spine WITHOUT and WITH contrast.

Question 19

Low back pain, surgical candidate?

Answer 19

MRI lumbar spine WITHOUT contrast.

Question 20

Low back pain, prior lumbar surgery?

Answer 20

MRI lumbar spine WITH and WITHOUT contrast.

Question 21

Dementia, suspected Alzheimer, NPH?

Answer 21

MRI head WITHOUT contrast.

Question 22

Focal neurologic deficits, single or multiple?

Answer 22

MRI head WITHOUT contrast or MRI head WITHOUT and WITH contrast.

Question 23

Focal neurologic deficit, sudden onset?

Answer 23

MRI head without contrast, MRI head WITHOUT and WITH contrast, or CT head WITHOUT.

Question 24

Change in mental status?

Answer 24

MRI head without or with contrast or CT head without.

Question 25

Vision loss, sudden, painless or painful?

Answer 25

MRI head and/or orbit without or with contrast.

Question 26

Vision loss with head trauma?

Answer 26

CT head and/or orbit with or without contrast - In subacute trauma, contrast may be useful.

Question 27

Head trauma, minimal clinical findings?

Answer 27

CT head WITHOUT contrast - Known to be low yield.