IMAGING CHOICES:IMAGING CHOICES:H d TH d THead to ToeHead to Toe

What to do when a ‘what is it’ What to do when a ‘what is it’ walks into your office walks into your office w s o yo o cw s o yo o c

MANY MODALITIESMANY MODALITIESMANY MODALITIESMANY MODALITIES

We want :We want :

1] Definitive 1] Definitive

2] Efficient2] Efficient

3] Cost effective3] Cost effective

CLINICAL ANALYSISCLINICAL ANALYSISCLINICAL ANALYSISCLINICAL ANALYSIS

Similar to your own diagnostic pathways:Similar to your own diagnostic pathways: Similar to your own diagnostic pathways:Similar to your own diagnostic pathways: Symptom basedSymptom based

E i b dE i b d Entity basedEntity based Most often combinedMost often combined

PRIMARY DIAGNOSISPRIMARY DIAGNOSISPRIMARY DIAGNOSISPRIMARY DIAGNOSIS

You and I are the first and foremost diagnosticYou and I are the first and foremost diagnostic You and I are the first and foremost diagnostic You and I are the first and foremost diagnostic toolstools

Tools that advance the workupTools that advance the workup that rule inthat rule in Tools that advance the workup Tools that advance the workup -- that rule in that rule in and rule outand rule outN l f d l i f hN l f d l i f h Not tools for secondary evaluation, after the Not tools for secondary evaluation, after the diagnosisdiagnosis

HEADHEADHEADHEAD

Acute: “ worst headache of my life ” orAcute: “ worst headache of my life ” or Acute: …worst headache of my life.. or Acute: …worst headache of my life.. or “...like a thunderclap…”“...like a thunderclap…”

DDX: Migraine etc; tumor infection but theDDX: Migraine etc; tumor infection but the DDX: Migraine, etc; tumor, infection, but the DDX: Migraine, etc; tumor, infection, but the real fear is SAH real fear is SAH –– 4040--50% mortality50% mortalityCT i i l 3% f l iCT i i l 3% f l i CT scan, very sensitive, only 3% false negative CT scan, very sensitive, only 3% false negative --LP if still suspiciousLP if still suspicious

Fast Fast -- important for agitated or confused patientimportant for agitated or confused patient

SAH posterior fossaSAH posterior fossaSAH posterior fossaSAH posterior fossaUnenhanced ctUnenhanced ct

SAH and aneurysmsSAH and aneurysmsSAH and aneurysmsSAH and aneurysms

MRI and MRA: SAHMRI and MRA: SAHMRI and MRA: SAHMRI and MRA: SAH

Subacute: sensitive and non invasiveSubacute: sensitive and non invasive Subacute: sensitive and non invasiveSubacute: sensitive and non invasive

Most other intracranial path:Most other intracranial path:MRIMRI

NeoplasmNeoplasm -- primaryprimary Neoplasm Neoplasm primaryprimary

NeoplasmNeoplasmNeoplasm Neoplasm

Pituitary adenoma metastasesPituitary adenoma metastases Pituitary adenoma metastasesPituitary adenoma metastases

MiscellanenousMiscellanenousMiscellanenousMiscellanenous

Demyelinating diseaseDemyelinating disease Demyelinating diseaseDemyelinating disease

HEAD AND NECKHEAD AND NECKHEAD AND NECKHEAD AND NECK

SPINESPINE SPINESPINE VESSELSVESSELS

THYROIDTHYROID THYROIDTHYROID AIRWAY AND THE REST, SINUSES ETCAIRWAY AND THE REST, SINUSES ETC

C SPINEC SPINEC SPINEC SPINE

T SPINET SPINET SPINET SPINE

L SPINEL SPINEL SPINEL SPINE

VESSELS, U/SVESSELS, U/SVESSELS, U/SVESSELS, U/S

CAROTIDCAROTID CAROTID CAROTID

NECK: VESSELS, MRANECK: VESSELS, MRANECK: VESSELS, MRANECK: VESSELS, MRA

NECK VESSELS, CTANECK VESSELS, CTANECK VESSELS, CTANECK VESSELS, CTA

THYROID, U/STHYROID, U/STHYROID, U/STHYROID, U/S

THYROID, NM SCANS AND THYROID, NM SCANS AND TTUPTAKESUPTAKES

NECK, ‘OTHER’NECK, ‘OTHER’NECK, OTHERNECK, OTHER

THE ‘REST’: SINUSESTHE ‘REST’: SINUSESTHE REST : SINUSESTHE REST : SINUSES

THE ’REST’ : FACIALTHE ’REST’ : FACIALTHE REST : FACIALTHE REST : FACIAL

CHESTCHESTCHESTCHEST

PEPE PEPE PARENCHYMAL DISEASEPARENCHYMAL DISEASE

ARTERIOARTERIO VASCULARVASCULAR ARTERIOARTERIO--VASCULARVASCULAR

PEPEPEPE

LUNG, EFFUSIONS,ETCLUNG, EFFUSIONS,ETCLUNG, EFFUSIONS,ETCLUNG, EFFUSIONS,ETC

VASCULAR, CTVASCULAR, CTVASCULAR, CTVASCULAR, CT

VASCULAR, MRAVASCULAR, MRAVASCULAR, MRAVASCULAR, MRA

ABDOMENABDOMENABDOMENABDOMEN

U/S CT NMU/S CT NM U/S , CT, NMU/S , CT, NM MRI secondary rolesMRI secondary roles

A h i i di d b dA h i i di d b d Approach is again mediated by symptoms and Approach is again mediated by symptoms and entity entity

BILIARY TREEBILIARY TREEBILIARY TREEBILIARY TREE

GB only 15GB only 15--20% gallstones have enough ca++20% gallstones have enough ca++ GB, only 15GB, only 15 20% gallstones have enough ca++ 20% gallstones have enough ca++ to be easily seen on film or ctto be easily seen on film or ct

BILIARY TREEBILIARY TREEBILIARY TREEBILIARY TREE

BILIARY TREE: BILIARY TREE: FUNCTIONALFUNCTIONAL

Nuclide scan with GB ejection fractionNuclide scan with GB ejection fractionNuclide scan with GB ejection fractionNuclide scan with GB ejection fractionvia cholecystokinin infusion via cholecystokinin infusion

PANCREASPANCREASPANCREASPANCREAS

Pancreatitis panc masses: CTPancreatitis panc masses: CT Pancreatitis, panc. masses: CTPancreatitis, panc. masses: CT

PANCREASPANCREASPANCREASPANCREAS

MRCPMRCPMRCPMRCP

Magnetic resonance cholangiopancreatographyMagnetic resonance cholangiopancreatography Magnetic resonance cholangiopancreatography Magnetic resonance cholangiopancreatography

MRCPMRCPMRCPMRCP

No contrast non invasive works even ifNo contrast non invasive works even if No contrast, non invasive, works even if No contrast, non invasive, works even if bilirubin is very highbilirubin is very high

RENAL CALCULIRENAL CALCULIRENAL CALCULIRENAL CALCULI

Ultrasound fast inexpensive no radiationUltrasound fast inexpensive no radiation Ultrasound, fast, inexpensive, no radiationUltrasound, fast, inexpensive, no radiation

RENAL STONE CTRENAL STONE CTRENAL STONE CTRENAL STONE CT

Fast more expensive very preciseFast more expensive very precise Fast, more expensive, very preciseFast, more expensive, very precise

LOWER ABD/PELVISLOWER ABD/PELVISLOWER ABD/PELVISLOWER ABD/PELVIS

Appendicitis diverticulitis etc: CT bestAppendicitis diverticulitis etc: CT best Appendicitis, diverticulitis, etc: CT bestAppendicitis, diverticulitis, etc: CT best

DIVERTICULITISDIVERTICULITISDIVERTICULITISDIVERTICULITIS

Fast nonFast non--invasive no prepinvasive no prep Fast, nonFast, non invasive, no prepinvasive, no prep

FEMALE PELVISFEMALE PELVISFEMALE PELVISFEMALE PELVIS

UltrasoundUltrasound -- fast cheaper very precisefast cheaper very precise Ultrasound Ultrasound fast, cheaper, very precisefast, cheaper, very precise

FEMALE PELVISFEMALE PELVISFEMALE PELVISFEMALE PELVIS

CT/PET FOR STAGINGCT/PET FOR STAGINGCT/PET FOR STAGINGCT/PET FOR STAGING

MALE REPROMALE REPROMALE REPROMALE REPRO

Ultrasound cheaper preciseUltrasound cheaper precise Ultrasound, cheaper, preciseUltrasound, cheaper, precise

SCROTALSCROTALSCROTALSCROTAL

MUSCULOSKELETALMUSCULOSKELETALMUSCULOSKELETALMUSCULOSKELETAL

Conventional radiography still vitalConventional radiography still vital Conventional radiography still vitalConventional radiography still vital “Internal derangement of joints” : MRI without “Internal derangement of joints” : MRI without

equal [ except fractures ]equal [ except fractures ]equal [ except fractures ]equal [ except fractures ] Many joints need MR Arthrography Many joints need MR Arthrography U/S good for screening some structures U/S good for screening some structures

SHOULDERSHOULDERSHOULDERSHOULDER

U/SU/SU/S U/S

U/SU/SU/SU/S

U/S VS MRIU/S VS MRIU/S VS MRIU/S VS MRI

SHOULDERSHOULDERSHOULDERSHOULDER

MRI RCMRI RCMRI RCMRI RC

ARM / ELBOWARM / ELBOWARM / ELBOWARM / ELBOW

WRIST / HANDWRIST / HANDWRIST / HANDWRIST / HAND

NonNon--arthrographicarthrographic NonNon arthrographicarthrographic

WRIST / HANDWRIST / HANDWRIST / HANDWRIST / HAND

HIPHIPHIPHIP

FemoroFemoro--acetabular impingement and labral tearsacetabular impingement and labral tears ––FemoroFemoro acetabular impingement and labral tears acetabular impingement and labral tears accelerated DJDaccelerated DJD

KNEEKNEEKNEEKNEE

Arthrography seldom neededArthrography seldom needed Arthrography seldom neededArthrography seldom needed

KNEEKNEEKNEEKNEE

Cartilage now well seenCartilage now well seen Cartilage now well seenCartilage now well seen

ANKLE / FOOTANKLE / FOOTANKLE / FOOTANKLE / FOOT

MRI is idealMRI is ideal MRI is idealMRI is ideal

FOOT / ANKLEFOOT / ANKLEFOOT / ANKLEFOOT / ANKLE

FOOTFOOTFOOTFOOT

DISTAL FOOTDISTAL FOOTDISTAL FOOTDISTAL FOOT

“CONSULTATION”“CONSULTATION”CONSULTATIONCONSULTATION

One of the best tools of allOne of the best tools of all One of the best tools of allOne of the best tools of all When we put our heads together and think When we put our heads together and think

about the patient’s situationabout the patient’s situationabout the patient s situationabout the patient s situation We really are available and happy to talk and We really are available and happy to talk and

l i h !l i h !plan with you!plan with you! 748748--4861 my cell4861 my cell 748748--4864 Dr. McCormick4864 Dr. McCormick