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acrac_69477_8

Dizziness and Ataxia

CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of isolated AVS. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of isolated AVS. CT Head Without IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. Patients with features of central vertigo or high baseline risk for stroke may be candidates for neuroimaging. Head CT allows for rapid evaluation of the intracranial structures. In isolated AVS, the detection rate of acute infarct may be as high at 11% at a single-center study involving 221 patients; therefore, noncontrast head CT may be of benefit in select patients [28]. Brain MRI may be useful for follow up evaluation if initial head CT is negative. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of isolated AVS. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of isolated AVS. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of isolated AVS. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of isolated AVS. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of isolated AVS. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of isolated AVS.

Dizziness and Ataxia. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of isolated AVS. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of isolated AVS. CT Head Without IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. Patients with features of central vertigo or high baseline risk for stroke may be candidates for neuroimaging. Head CT allows for rapid evaluation of the intracranial structures. In isolated AVS, the detection rate of acute infarct may be as high at 11% at a single-center study involving 221 patients; therefore, noncontrast head CT may be of benefit in select patients [28]. Brain MRI may be useful for follow up evaluation if initial head CT is negative. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of isolated AVS. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of isolated AVS. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of isolated AVS. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of isolated AVS. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of isolated AVS. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of isolated AVS.

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acrac_69477_9

Dizziness and Ataxia

MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of isolated AVS. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of isolated AVS. Dizziness and Ataxia MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of isolated AVS. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of isolated AVS. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of isolated AVS. MRI Head and Internal Auditory Canal Without and With IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. Routine MRI of the head in the setting of vestibular neuritis, the most common cause of isolated AVS, is characteristically normal. Dedicated imaging of the IACs allows for improved evaluation of the vestibular nerve and may show a decreased caliber of the nerve following vestibular neuritis; however, this is not always present and is not required to establish the diagnosis [34,35]. Detection of vestibular nerve enhancement following the IV administration of gadolinium- containing contrast would also support the clinical diagnosis of vestibular neuritis [36]. Labyrinthitis, another common cause of AVS, may also have findings on contrast-enhanced MRI of the IACs; however, this is often diagnosed clinically due to the presence of associated hearing loss or tinnitus and will be discussed separately (Variant 4) [1].

Dizziness and Ataxia. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of isolated AVS. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of isolated AVS. Dizziness and Ataxia MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of isolated AVS. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of isolated AVS. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of isolated AVS. MRI Head and Internal Auditory Canal Without and With IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. Routine MRI of the head in the setting of vestibular neuritis, the most common cause of isolated AVS, is characteristically normal. Dedicated imaging of the IACs allows for improved evaluation of the vestibular nerve and may show a decreased caliber of the nerve following vestibular neuritis; however, this is not always present and is not required to establish the diagnosis [34,35]. Detection of vestibular nerve enhancement following the IV administration of gadolinium- containing contrast would also support the clinical diagnosis of vestibular neuritis [36]. Labyrinthitis, another common cause of AVS, may also have findings on contrast-enhanced MRI of the IACs; however, this is often diagnosed clinically due to the presence of associated hearing loss or tinnitus and will be discussed separately (Variant 4) [1].

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acrac_69477_10

Dizziness and Ataxia

MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of isolated AVS. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of isolated AVS. MRI Head Without and With IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. MRI of the head without and with IV contrast would be the imaging modality of choice to evaluate demyelinating, autoimmune, inflammatory, or metabolic conditions involving the brainstem or cerebellum, which would all be rare causes of isolated AVS [25]. Although brain parenchymal signal alterations would be demonstrable on precontrast imaging, the addition of gadolinium-containing IV contrast allows for the differentiation of acute and chronic demyelinating lesions as well as detection of other acute inflammation. MRI Head Without IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. Because routine MRI of the head is characteristically normal in vestibular neuritis, MRI is not required for diagnosis. Patients with features of central vertigo or high baseline risk for stroke may be candidates for neuroimaging. In patients with isolated dizziness symptoms without associated neurological symptoms, the incidence of acute central lesions was 2.3% on MRI in a single center of 645 patients presented to the emergency department [37]. The presence of white matter abnormalities identified on MRI of the head, however, has been shown to positively correlate with the risk of developing subsequent chronic vestibular insufficiency and so may be prognostically useful especially in the elderly population [38]. Approximately 3% to 4% of patients presenting with isolated dizziness had acute stroke on MRI DWI [39]. MRI also has a better sensitivity than CT for the detection of parenchymal infarcts.

Dizziness and Ataxia. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of isolated AVS. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of isolated AVS. MRI Head Without and With IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. MRI of the head without and with IV contrast would be the imaging modality of choice to evaluate demyelinating, autoimmune, inflammatory, or metabolic conditions involving the brainstem or cerebellum, which would all be rare causes of isolated AVS [25]. Although brain parenchymal signal alterations would be demonstrable on precontrast imaging, the addition of gadolinium-containing IV contrast allows for the differentiation of acute and chronic demyelinating lesions as well as detection of other acute inflammation. MRI Head Without IV Contrast Imaging evaluation in isolated AVS without features of central vertigo is unnecessary. Because routine MRI of the head is characteristically normal in vestibular neuritis, MRI is not required for diagnosis. Patients with features of central vertigo or high baseline risk for stroke may be candidates for neuroimaging. In patients with isolated dizziness symptoms without associated neurological symptoms, the incidence of acute central lesions was 2.3% on MRI in a single center of 645 patients presented to the emergency department [37]. The presence of white matter abnormalities identified on MRI of the head, however, has been shown to positively correlate with the risk of developing subsequent chronic vestibular insufficiency and so may be prognostically useful especially in the elderly population [38]. Approximately 3% to 4% of patients presenting with isolated dizziness had acute stroke on MRI DWI [39]. MRI also has a better sensitivity than CT for the detection of parenchymal infarcts.

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acrac_69477_11

Dizziness and Ataxia

Studies of patients presenting with AVS related to infarct have shown an overall sensitivity of approximately 80% for MRI performed within 24 hours of symptom onset. Early MRI, however, may be negative in half of cases when the area of infarct is small (<10 mm in size) and located in the brainstem/cerebellum. Patients with these small areas of infarct are also those more likely to present with isolated AVS. In these cases, delaying MRI until at least 48 hours from symptom onset or repeating an initially negative MRI will improve lesion detection [29]. Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging. Posterior circulation strokes involving the brainstem and cerebellum account for a smaller proportion of acute stroke presentations but may have severe devastating and debilitating consequences. It is estimated that 25% of AVS are caused by stroke. Approximately 20% of these patients have focal neurologic signs whereas the remainder have Dizziness and Ataxia CT Head With IV Contrast There is no relevant literature regarding the use of postcontrast head CT in the evaluation of suspected acute posterior fossa stroke. CT Head Without and With IV Contrast There is no relevant literature regarding the use of postcontrast head CT in the evaluation of suspected acute posterior fossa stroke. CT Head Without IV Contrast CT is usually performed first in the emergency setting for workup of acute stroke. Hemorrhage can be excluded rapidly to select patients for thrombolysis. Posterior fossa ischemic strokes are difficult to detect on CT with a low sensitivity (~10% at a single academic emergency department in 610 patients in a 2-year period) [6].

Dizziness and Ataxia. Studies of patients presenting with AVS related to infarct have shown an overall sensitivity of approximately 80% for MRI performed within 24 hours of symptom onset. Early MRI, however, may be negative in half of cases when the area of infarct is small (<10 mm in size) and located in the brainstem/cerebellum. Patients with these small areas of infarct are also those more likely to present with isolated AVS. In these cases, delaying MRI until at least 48 hours from symptom onset or repeating an initially negative MRI will improve lesion detection [29]. Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging. Posterior circulation strokes involving the brainstem and cerebellum account for a smaller proportion of acute stroke presentations but may have severe devastating and debilitating consequences. It is estimated that 25% of AVS are caused by stroke. Approximately 20% of these patients have focal neurologic signs whereas the remainder have Dizziness and Ataxia CT Head With IV Contrast There is no relevant literature regarding the use of postcontrast head CT in the evaluation of suspected acute posterior fossa stroke. CT Head Without and With IV Contrast There is no relevant literature regarding the use of postcontrast head CT in the evaluation of suspected acute posterior fossa stroke. CT Head Without IV Contrast CT is usually performed first in the emergency setting for workup of acute stroke. Hemorrhage can be excluded rapidly to select patients for thrombolysis. Posterior fossa ischemic strokes are difficult to detect on CT with a low sensitivity (~10% at a single academic emergency department in 610 patients in a 2-year period) [6].

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acrac_69477_12

Dizziness and Ataxia

Overall, the diagnostic yield for head CT ordered in the emergency department for acute dizziness is low (2.2%; 1.6% for emergent findings in an academic emergency department in 448 patients), but MRI changes the diagnosis up to 16% of the time, acutely in 8% of cases [2]. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of suspected acute posterior fossa stroke. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of suspected acute posterior fossa stroke. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of suspected acute posterior fossa stroke. CTA Head and Neck With IV Contrast CTA head and neck may be performed for evaluation of suspected acute posterior fossa stroke, particularly those who are eligible for mechanical thrombectomy. MRA Head and Neck With IV Contrast MRA head and neck may be performed for the evaluation of acute ischemic strokes and may assist in the management of patients, particularly those who are eligible for mechanical thrombectomy. The decision between CTA and MRA for initial vascular evaluation may depend on institutional preferences. MRA Head and Neck Without and With IV Contrast MRA head and neck may be performed for the evaluation of acute ischemic strokes and may assist in the management of patients, particularly those who are eligible for mechanical thrombectomy. The decision between CTA and MRA for initial vascular evaluation may depend on institutional preferences. Dizziness and Ataxia MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of suspected acute posterior fossa stroke.

Dizziness and Ataxia. Overall, the diagnostic yield for head CT ordered in the emergency department for acute dizziness is low (2.2%; 1.6% for emergent findings in an academic emergency department in 448 patients), but MRI changes the diagnosis up to 16% of the time, acutely in 8% of cases [2]. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of suspected acute posterior fossa stroke. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of suspected acute posterior fossa stroke. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of suspected acute posterior fossa stroke. CTA Head and Neck With IV Contrast CTA head and neck may be performed for evaluation of suspected acute posterior fossa stroke, particularly those who are eligible for mechanical thrombectomy. MRA Head and Neck With IV Contrast MRA head and neck may be performed for the evaluation of acute ischemic strokes and may assist in the management of patients, particularly those who are eligible for mechanical thrombectomy. The decision between CTA and MRA for initial vascular evaluation may depend on institutional preferences. MRA Head and Neck Without and With IV Contrast MRA head and neck may be performed for the evaluation of acute ischemic strokes and may assist in the management of patients, particularly those who are eligible for mechanical thrombectomy. The decision between CTA and MRA for initial vascular evaluation may depend on institutional preferences. Dizziness and Ataxia MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of suspected acute posterior fossa stroke.

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acrac_69477_13

Dizziness and Ataxia

MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head With IV Contrast There is no relevant literature regarding the use of postcontrast brain MRI in the evaluation of suspected acute posterior fossa stroke. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of postcontrast brain MRI in the evaluation of suspected acute posterior fossa stroke. MRI Head Without IV Contrast The ability to detect an acute stroke on DWI is dependent on size [29]. False-negative MRIs with small strokes occurred 6 to 48 hours after the onset of vestibular symptoms. In this retrospective study, central oculomotor signs (odds ratio [OR] 2.8, 95% confidence interval [CI], 1.5-5.2) and focal abnormalities on clinical examination (OR 3.3, 95% CI, 1.8-6.2) are statistically significantly positive predictors for abnormal brain lesions on CT/MRI, whereas the transient nature of symptoms was associated with a reduced risk (OR 0.3, 95% CI, 0.1-0.6).

Dizziness and Ataxia. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of suspected acute posterior fossa stroke. MRI Head With IV Contrast There is no relevant literature regarding the use of postcontrast brain MRI in the evaluation of suspected acute posterior fossa stroke. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of postcontrast brain MRI in the evaluation of suspected acute posterior fossa stroke. MRI Head Without IV Contrast The ability to detect an acute stroke on DWI is dependent on size [29]. False-negative MRIs with small strokes occurred 6 to 48 hours after the onset of vestibular symptoms. In this retrospective study, central oculomotor signs (odds ratio [OR] 2.8, 95% confidence interval [CI], 1.5-5.2) and focal abnormalities on clinical examination (OR 3.3, 95% CI, 1.8-6.2) are statistically significantly positive predictors for abnormal brain lesions on CT/MRI, whereas the transient nature of symptoms was associated with a reduced risk (OR 0.3, 95% CI, 0.1-0.6).

69477

acrac_69477_14

Dizziness and Ataxia

In a study of emergency department patients with dizziness, combined neurological symptoms with an OR of 16.72, P < . 01, was found to be the strongest predictor of a lesion positive on MRI [37]. In a cross-sectional study of 190 high-risk patients with dizziness, HINTS examination outperforms ABCD2 risk scores [30]. The diagnostic yield for head CT ordered in the emergency department for acute dizziness is low (2.2%; 1.6% for emergent findings), but MRI changes the diagnosis up to 16% of the time, acutely in 8% of cases [2]. Earlier MRI studies in posterior fossa stroke showed a high false-negative rate on DWI when performed within the first 24 hours of symptom onset [44,45]. This has improved with better imaging techniques over time. MRI has a higher sensitivity for acute ischemic strokes than CT, although within the first 48 hours DWI still can be falsely negative in approximately 50% of small ischemic strokes in the posterior fossa [6,46]. Some have advocated for delayed MRI (3-7 days) if initial imaging was negative [1,29]. One single-center study of 36 patients with basilar artery occlusion found DWI MRI helps predict outcome in basilar artery occlusion patients treated with intra-arterial thrombolysis [47]. Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging. In contrast to an isolated episode of acute vertigo, chronic recurrent vertigo suggests an intermittently symptomatic long-standing condition. When associated unilateral hearing loss or tinnitus is present, the diagnosis of MD should be considered. MD is of unknown etiology. Patients have intermittent episodes of vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Previously a purely clinical diagnosis, imaging in MD has increased in the past decade. It is associated with endolymphatic hydrops (distension of labyrinthine structures). Imaging may also Dizziness and Ataxia

Dizziness and Ataxia. In a study of emergency department patients with dizziness, combined neurological symptoms with an OR of 16.72, P < . 01, was found to be the strongest predictor of a lesion positive on MRI [37]. In a cross-sectional study of 190 high-risk patients with dizziness, HINTS examination outperforms ABCD2 risk scores [30]. The diagnostic yield for head CT ordered in the emergency department for acute dizziness is low (2.2%; 1.6% for emergent findings), but MRI changes the diagnosis up to 16% of the time, acutely in 8% of cases [2]. Earlier MRI studies in posterior fossa stroke showed a high false-negative rate on DWI when performed within the first 24 hours of symptom onset [44,45]. This has improved with better imaging techniques over time. MRI has a higher sensitivity for acute ischemic strokes than CT, although within the first 48 hours DWI still can be falsely negative in approximately 50% of small ischemic strokes in the posterior fossa [6,46]. Some have advocated for delayed MRI (3-7 days) if initial imaging was negative [1,29]. One single-center study of 36 patients with basilar artery occlusion found DWI MRI helps predict outcome in basilar artery occlusion patients treated with intra-arterial thrombolysis [47]. Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging. In contrast to an isolated episode of acute vertigo, chronic recurrent vertigo suggests an intermittently symptomatic long-standing condition. When associated unilateral hearing loss or tinnitus is present, the diagnosis of MD should be considered. MD is of unknown etiology. Patients have intermittent episodes of vertigo, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Previously a purely clinical diagnosis, imaging in MD has increased in the past decade. It is associated with endolymphatic hydrops (distension of labyrinthine structures). Imaging may also Dizziness and Ataxia

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acrac_69477_15

Dizziness and Ataxia

be used to exclude other causes of such symptoms, such as vestibular schwannoma, superior semicircular dehiscence, and other IAC masses. Most imaging facilities are unable to perform the specific type of MRI required for evaluation of endolymphatic hydrops. Outside of academic medical centers with specialized imaging protocols, IAC MRI is usually performed to negatively exclude other causes of vertigo with unilateral hearing loss or tinnitus, rather than to make a positive imaging-based diagnosis of MD. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of suspected MD. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of suspected MD. CT Head Without IV Contrast There is no relevant literature regarding the use of CT head without IV contrast in the evaluation of suspected MD. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of suspected MD. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of suspected MD. CT Temporal Bone Without IV Contrast Superior semicircular canal dehiscence, which can present with similar symptoms to MD, can be readily diagnosed on a CT temporal bone without IV contrast. Three-dimensional CT temporal bone may be used for the evaluation of stenosis of the vestibular aqueduct [48,49] and high jugular bulb in patients with suspected MD [50]. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of suspected MD. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of suspected MD.

Dizziness and Ataxia. be used to exclude other causes of such symptoms, such as vestibular schwannoma, superior semicircular dehiscence, and other IAC masses. Most imaging facilities are unable to perform the specific type of MRI required for evaluation of endolymphatic hydrops. Outside of academic medical centers with specialized imaging protocols, IAC MRI is usually performed to negatively exclude other causes of vertigo with unilateral hearing loss or tinnitus, rather than to make a positive imaging-based diagnosis of MD. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of suspected MD. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of suspected MD. CT Head Without IV Contrast There is no relevant literature regarding the use of CT head without IV contrast in the evaluation of suspected MD. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of suspected MD. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of suspected MD. CT Temporal Bone Without IV Contrast Superior semicircular canal dehiscence, which can present with similar symptoms to MD, can be readily diagnosed on a CT temporal bone without IV contrast. Three-dimensional CT temporal bone may be used for the evaluation of stenosis of the vestibular aqueduct [48,49] and high jugular bulb in patients with suspected MD [50]. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of suspected MD. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of suspected MD.

69477

acrac_69477_16

Dizziness and Ataxia

MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of suspected MD. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of suspected MD. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of suspected MD. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of suspected MD. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of suspected MD. Dizziness and Ataxia Highly specialized techniques with high resolution such as delayed 3-D fluid-attenuated inversion recovery (FLAIR), inversion recovery turbo spin-echo with real reconstruction (3-D real-inversion recovery), and imaged after gadolinium administration demonstrates accumulation of gadolinium in the endolymphatic sac [53-57]. Intratympanic gadolinium may also be performed but is more invasive [58,59]. Some studies used double dose contrast. Volumetric assessment with ratio of endolymph to perilymph volume in the cochlea and vestibule are performed. Endolymphatic hydrops and grading on MRI in patients with MD has shown correlation with clinical symptoms in multiple studies [52,60-64] and histopathologic specimens [65]. The vestibular endolymphatic space contacting the oval window has a high specificity and positive predictive value in differentiating MD ears from other ears in a small study [66].

Dizziness and Ataxia. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of suspected MD. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of suspected MD. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of suspected MD. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of suspected MD. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of suspected MD. Dizziness and Ataxia Highly specialized techniques with high resolution such as delayed 3-D fluid-attenuated inversion recovery (FLAIR), inversion recovery turbo spin-echo with real reconstruction (3-D real-inversion recovery), and imaged after gadolinium administration demonstrates accumulation of gadolinium in the endolymphatic sac [53-57]. Intratympanic gadolinium may also be performed but is more invasive [58,59]. Some studies used double dose contrast. Volumetric assessment with ratio of endolymph to perilymph volume in the cochlea and vestibule are performed. Endolymphatic hydrops and grading on MRI in patients with MD has shown correlation with clinical symptoms in multiple studies [52,60-64] and histopathologic specimens [65]. The vestibular endolymphatic space contacting the oval window has a high specificity and positive predictive value in differentiating MD ears from other ears in a small study [66].

69477

acrac_69477_17

Dizziness and Ataxia

Although most of the recent studies have been focused on the postgadolinium enhancement, the noncontrast portion of the MR studies can be helpful in diagnosing alternative causes such as stroke, superior semicircular dehiscence, and other IAC masses. Volumetric measure of inner ear structures has been shown to be useful [67]. Although often not specifically mentioned, a sequence (typically heavily T2-weighted) that shows both perilymph and endolymph to help determine the area of the entire labyrinth is needed, and this is performed without IV contrast. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of suspected MD. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of suspected MD. MRI Head Without IV Contrast There is no relevant literature regarding the use of MRI head without IV contrast in the evaluation of suspected MD. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of suspected VBI. Dizziness and Ataxia CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of suspected VBI. CT Head Without IV Contrast CT head without IV contrast may be useful in the evaluation of suspected VBI, although brain MRI is expected to be more sensitive for the detection of posterior fossa infarcts. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of suspected VBI. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of suspected VBI.

Dizziness and Ataxia. Although most of the recent studies have been focused on the postgadolinium enhancement, the noncontrast portion of the MR studies can be helpful in diagnosing alternative causes such as stroke, superior semicircular dehiscence, and other IAC masses. Volumetric measure of inner ear structures has been shown to be useful [67]. Although often not specifically mentioned, a sequence (typically heavily T2-weighted) that shows both perilymph and endolymph to help determine the area of the entire labyrinth is needed, and this is performed without IV contrast. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of suspected MD. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of suspected MD. MRI Head Without IV Contrast There is no relevant literature regarding the use of MRI head without IV contrast in the evaluation of suspected MD. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of suspected VBI. Dizziness and Ataxia CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of suspected VBI. CT Head Without IV Contrast CT head without IV contrast may be useful in the evaluation of suspected VBI, although brain MRI is expected to be more sensitive for the detection of posterior fossa infarcts. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of suspected VBI. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of suspected VBI.

69477

acrac_69477_18

Dizziness and Ataxia

CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of suspected VBI. CTA Head and Neck With IV Contrast CTA allows for the evaluation of the course and luminal caliber of the studied arteries. CTA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. In cases of vertebral artery dissection confirmed by conventional angiography, CTA has the highest reported sensitivity (100%), followed by MRA (77%) and Doppler US (71%), in a systematic review of 75 observational studies. Because symptomatic dissection may involve any portion of the vertebral artery, from the origin at the aortic arch branch vessels to the basilar artery, the entirety of the vessel should be included for evaluation [14]. MRA Head and Neck With IV Contrast MRA allows for evaluation of the course and luminal caliber of the arteries. MRA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. MRA of the head and neck can be performed without IV contrast, with IV contrast, or as a combination of without and with IV contrast. Although 3-D time-of-flight MRA of the head is typically diagnostic without the use of IV gadolinium- based contrast agents, MRA of the neck is often best performed with contrast for better evaluation of the vessels with increased spatial resolution and decreased flow-related artifacts. In a study comparing the diagnostic performance of contrast-enhanced MRA of the neck to digital subtraction angiography in evaluation of vertebral artery origin stenosis, the sensitivity, specificity, and accuracy of MRA were shown to be as high as 97%, 98%, and 93%, respectively, in 49 patients [69]. However, MRA has not demonstrated significant differences in the degree of arterial stenosis between symptomatic patients with VBI and asymptomatic controls [13].

Dizziness and Ataxia. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of suspected VBI. CTA Head and Neck With IV Contrast CTA allows for the evaluation of the course and luminal caliber of the studied arteries. CTA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. In cases of vertebral artery dissection confirmed by conventional angiography, CTA has the highest reported sensitivity (100%), followed by MRA (77%) and Doppler US (71%), in a systematic review of 75 observational studies. Because symptomatic dissection may involve any portion of the vertebral artery, from the origin at the aortic arch branch vessels to the basilar artery, the entirety of the vessel should be included for evaluation [14]. MRA Head and Neck With IV Contrast MRA allows for evaluation of the course and luminal caliber of the arteries. MRA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. MRA of the head and neck can be performed without IV contrast, with IV contrast, or as a combination of without and with IV contrast. Although 3-D time-of-flight MRA of the head is typically diagnostic without the use of IV gadolinium- based contrast agents, MRA of the neck is often best performed with contrast for better evaluation of the vessels with increased spatial resolution and decreased flow-related artifacts. In a study comparing the diagnostic performance of contrast-enhanced MRA of the neck to digital subtraction angiography in evaluation of vertebral artery origin stenosis, the sensitivity, specificity, and accuracy of MRA were shown to be as high as 97%, 98%, and 93%, respectively, in 49 patients [69]. However, MRA has not demonstrated significant differences in the degree of arterial stenosis between symptomatic patients with VBI and asymptomatic controls [13].

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Dizziness and Ataxia

In cases of vertebral artery dissection confirmed by conventional angiography, CTA has the highest reported sensitivity (100%), followed by MRA (77%) and Doppler US (71%). The addition of nonluminal vessel wall imaging sequences likely improves the detection of nonstenotic arterial dissection, but it is unclear whether these types of lesions would result in VBI. Because symptomatic dissection may involve any portion of the vertebral artery, from the origin at the aortic arch branch vessels to the basilar artery, the entirety of the vessel should be included for evaluation [14]. MRA Head and Neck Without and With IV Contrast MRA allows for the evaluation of the course and luminal caliber of the arteries. MRA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. MRA of the head and neck can be performed without IV contrast, with IV contrast, or as a combination of without and with IV contrast. Although 3-D time-of-flight MRA of the head is typically diagnostic without the use of IV gadolinium- based contrast agents, MRA of the neck is often best performed with contrast for better evaluation of the vessels with increased spatial resolution and decreased flow-related artifacts. In a study comparing the diagnostic performance of contrast-enhanced MRA of the neck to digital subtraction angiography in evaluation of vertebral artery origin stenosis, the sensitivity, specificity, and accuracy of MRA were shown to be as high as 97%, 98%, and 93%, respectively in 49 patients [69]. However, MRA has not demonstrated significant differences in the degree of arterial stenosis between symptomatic patients with VBI and asymptomatic controls [13]. In cases of vertebral artery dissection confirmed by conventional angiography, CTA has the highest Dizziness and Ataxia reported sensitivity (100%), followed by MRA (77%) and Doppler US (71%).

Dizziness and Ataxia. In cases of vertebral artery dissection confirmed by conventional angiography, CTA has the highest reported sensitivity (100%), followed by MRA (77%) and Doppler US (71%). The addition of nonluminal vessel wall imaging sequences likely improves the detection of nonstenotic arterial dissection, but it is unclear whether these types of lesions would result in VBI. Because symptomatic dissection may involve any portion of the vertebral artery, from the origin at the aortic arch branch vessels to the basilar artery, the entirety of the vessel should be included for evaluation [14]. MRA Head and Neck Without and With IV Contrast MRA allows for the evaluation of the course and luminal caliber of the arteries. MRA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. MRA of the head and neck can be performed without IV contrast, with IV contrast, or as a combination of without and with IV contrast. Although 3-D time-of-flight MRA of the head is typically diagnostic without the use of IV gadolinium- based contrast agents, MRA of the neck is often best performed with contrast for better evaluation of the vessels with increased spatial resolution and decreased flow-related artifacts. In a study comparing the diagnostic performance of contrast-enhanced MRA of the neck to digital subtraction angiography in evaluation of vertebral artery origin stenosis, the sensitivity, specificity, and accuracy of MRA were shown to be as high as 97%, 98%, and 93%, respectively in 49 patients [69]. However, MRA has not demonstrated significant differences in the degree of arterial stenosis between symptomatic patients with VBI and asymptomatic controls [13]. In cases of vertebral artery dissection confirmed by conventional angiography, CTA has the highest Dizziness and Ataxia reported sensitivity (100%), followed by MRA (77%) and Doppler US (71%).

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Dizziness and Ataxia

The addition of nonluminal vessel wall imaging sequences likely improves the detection of nonstenotic arterial dissection, but it is unclear whether these types of lesions would result in VBI. Because symptomatic dissection may involve any portion of the vertebral artery, from the origin at the aortic arch branch vessels to the basilar artery, the entirety of the vessel should be included for evaluation [14]. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of suspected VBI. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of suspected VBI. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of suspected VBI. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of suspected VBI. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of suspected VBI. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of suspected VBI. MRI Head Without and With IV Contrast MRI allows for detailed evaluation of the intracranial structures with improved soft tissue resolution when compared with CT. MRI before and after the administration of gadolinium-containing IV contrast allows for the additional characterization of these tissues and improved detection of intracranial pathology.

Dizziness and Ataxia. The addition of nonluminal vessel wall imaging sequences likely improves the detection of nonstenotic arterial dissection, but it is unclear whether these types of lesions would result in VBI. Because symptomatic dissection may involve any portion of the vertebral artery, from the origin at the aortic arch branch vessels to the basilar artery, the entirety of the vessel should be included for evaluation [14]. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of suspected VBI. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of suspected VBI. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of suspected VBI. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of suspected VBI. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of suspected VBI. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of suspected VBI. MRI Head Without and With IV Contrast MRI allows for detailed evaluation of the intracranial structures with improved soft tissue resolution when compared with CT. MRI before and after the administration of gadolinium-containing IV contrast allows for the additional characterization of these tissues and improved detection of intracranial pathology.

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Dizziness and Ataxia

In the setting of VBI, high- resolution vessel wall imaging of the posterior circulation using IV contrast may be of use as both a diagnostic and prognostic tool, but it is not used as initial imaging in the evaluation of suspected VBI. In a single-center study of 219 patients, when compared with MRA, atherosclerotic plaque in the basilar artery and associated luminal stenosis of >50% was more often identified on vessel wall imaging; however, the degree of narrowing was felt to be likely overestimated. Although atherosclerotic vessel narrowing can certainly result in VBI, the clinical applicability of these findings on vessel wall imaging has yet to be fully elucidated [70]. Interestingly, the degree of vessel wall enhancement in basilar artery stenosis on vessel wall imaging has been shown to correlate with the risk of subsequent infarct and may serve as a noninvasive prognostic marker in patients with VBI [71]. Additionally, alterations of perfusion parameters using arterial-spin labelling in the brain has been shown to correlate with the presence and severity of vertebrobasilar stenosis and serves as an adjunct to contrast-enhanced imaging of the vessel wall as well as luminal imaging via MRA/CTA [68]. MRI Head Without IV Contrast MRI head without IV contrast is useful in the evaluation of VBI and for the detection of posterior fossa infarcts. A negative MRI does not exclude the possibility of chronic ischemia without completed infarction and therefore does not replace the need for vascular imaging. Dizziness and Ataxia Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging. Disequilibrium refers to a sensation of imbalance, unsteadiness, or instability. Disequilibrium in addition to loss of muscle coordination is a common finding in cerebellar ataxia, which indicates loss of coordination due to loss of normal motor control by the cerebellum.

Dizziness and Ataxia. In the setting of VBI, high- resolution vessel wall imaging of the posterior circulation using IV contrast may be of use as both a diagnostic and prognostic tool, but it is not used as initial imaging in the evaluation of suspected VBI. In a single-center study of 219 patients, when compared with MRA, atherosclerotic plaque in the basilar artery and associated luminal stenosis of >50% was more often identified on vessel wall imaging; however, the degree of narrowing was felt to be likely overestimated. Although atherosclerotic vessel narrowing can certainly result in VBI, the clinical applicability of these findings on vessel wall imaging has yet to be fully elucidated [70]. Interestingly, the degree of vessel wall enhancement in basilar artery stenosis on vessel wall imaging has been shown to correlate with the risk of subsequent infarct and may serve as a noninvasive prognostic marker in patients with VBI [71]. Additionally, alterations of perfusion parameters using arterial-spin labelling in the brain has been shown to correlate with the presence and severity of vertebrobasilar stenosis and serves as an adjunct to contrast-enhanced imaging of the vessel wall as well as luminal imaging via MRA/CTA [68]. MRI Head Without IV Contrast MRI head without IV contrast is useful in the evaluation of VBI and for the detection of posterior fossa infarcts. A negative MRI does not exclude the possibility of chronic ischemia without completed infarction and therefore does not replace the need for vascular imaging. Dizziness and Ataxia Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging. Disequilibrium refers to a sensation of imbalance, unsteadiness, or instability. Disequilibrium in addition to loss of muscle coordination is a common finding in cerebellar ataxia, which indicates loss of coordination due to loss of normal motor control by the cerebellum.

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Dizziness and Ataxia

Cerebellar ataxia includes a variety of clinical conditions characterized by neurodegeneration of the cerebellum and/or brainstem and may result from inherited or sporadic etiologies. The current classification system for the inherited cerebellar ataxias includes autosomal dominant spinocerebellar, autosomal recessive, congenital, mitochondrial, X-linked, and sporadic types. Autosomal ataxias have complex genetic heterogeneity and variable phenotypic expression, which makes diagnosis difficult [72]. Adult-onset sporadic ataxia encompasses a more heterogeneous group of etiologies, which includes toxic/nutritional, immune- mediated, infectious, degenerative, and reclassification as having a genetic basis [73]. Some patients with cerebellar ataxia may also have coexisting symptoms of central or peripheral vestibulopathy, which can further confound the clinic picture [74]. Imaging in cerebellar ataxia is aimed at primarily detecting parenchymal injury in the form of volume loss or alternations in attenuation (CT) or signal intensity (MRI). Patterns of parenchymal injury may suggest a certain ataxia subtype; however, there is a significant overlap of imaging features among various etiologies, and conventional neuroimaging may be unremarkable in early disease. As such, diagnosis relies on the combination of history, a thorough clinical neurologic examination, and imaging with confirmatory laboratory and/or genetic testing based on these findings [73]. In some forms of ataxia, detection of abnormal iron deposition or calcification may also be helpful [75,76]. Finally, imaging is also important to exclude nondegenerative central etiologies of ataxia such as mass lesion or infarct [77]. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of cerebellar ataxia. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of cerebellar ataxia.

Dizziness and Ataxia. Cerebellar ataxia includes a variety of clinical conditions characterized by neurodegeneration of the cerebellum and/or brainstem and may result from inherited or sporadic etiologies. The current classification system for the inherited cerebellar ataxias includes autosomal dominant spinocerebellar, autosomal recessive, congenital, mitochondrial, X-linked, and sporadic types. Autosomal ataxias have complex genetic heterogeneity and variable phenotypic expression, which makes diagnosis difficult [72]. Adult-onset sporadic ataxia encompasses a more heterogeneous group of etiologies, which includes toxic/nutritional, immune- mediated, infectious, degenerative, and reclassification as having a genetic basis [73]. Some patients with cerebellar ataxia may also have coexisting symptoms of central or peripheral vestibulopathy, which can further confound the clinic picture [74]. Imaging in cerebellar ataxia is aimed at primarily detecting parenchymal injury in the form of volume loss or alternations in attenuation (CT) or signal intensity (MRI). Patterns of parenchymal injury may suggest a certain ataxia subtype; however, there is a significant overlap of imaging features among various etiologies, and conventional neuroimaging may be unremarkable in early disease. As such, diagnosis relies on the combination of history, a thorough clinical neurologic examination, and imaging with confirmatory laboratory and/or genetic testing based on these findings [73]. In some forms of ataxia, detection of abnormal iron deposition or calcification may also be helpful [75,76]. Finally, imaging is also important to exclude nondegenerative central etiologies of ataxia such as mass lesion or infarct [77]. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of cerebellar ataxia. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of cerebellar ataxia.

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Dizziness and Ataxia

CT Head Without IV Contrast Head CT allows for evaluation of the intracranial structures; however, soft tissue contrast is inferior to MRI. Certain materials, however, are more conspicuous on CT imaging including calcification. Rare subtypes of SCA may show calcification within the brain parenchyma; however, other more common brain parenchymal changes in patients with cerebellar ataxia are best evaluated with MRI [76]. Additionally, parenchymal calcification can often be adequately detected and characterized on MRI. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of cerebellar ataxia. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of cerebellar ataxia. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of cerebellar ataxia. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of cerebellar ataxia. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of cerebellar ataxia. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of cerebellar ataxia. Dizziness and Ataxia MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of cerebellar ataxia. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of cerebellar ataxia.

Dizziness and Ataxia. CT Head Without IV Contrast Head CT allows for evaluation of the intracranial structures; however, soft tissue contrast is inferior to MRI. Certain materials, however, are more conspicuous on CT imaging including calcification. Rare subtypes of SCA may show calcification within the brain parenchyma; however, other more common brain parenchymal changes in patients with cerebellar ataxia are best evaluated with MRI [76]. Additionally, parenchymal calcification can often be adequately detected and characterized on MRI. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of cerebellar ataxia. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of cerebellar ataxia. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of cerebellar ataxia. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of cerebellar ataxia. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of cerebellar ataxia. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of cerebellar ataxia. Dizziness and Ataxia MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of cerebellar ataxia. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of cerebellar ataxia.

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Dizziness and Ataxia

MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of cerebellar ataxia. MRI Cervical and Thoracic Spine Without IV Contrast MRI of the spine allows for evaluation of the spinal column as well as the soft tissues within and surrounding the spinal column including the spinal cord. Atrophy of the cervical spinal cord on MRI has been described in SCA type 1 (SCA1) and shown to be correlated with symptom severity, disease duration, and the number of pathologic cytosine, adenine, and guanine repeats, which serves at the genetic cause of SCA1 [78]. Similar atrophy has been reported in SCA type 7, Friedreich ataxia, and ataxia with vitamin E deficiency [79,80]. Spinal findings were associated with abnormalities of the brain parenchyma and generally not reported in isolation. Imaging of the spinal cord in other forms of cerebellar ataxia has either been reported as normal or, more often, not specifically described in the literature [81]. Spine MRI may be considered in patients with cerebellar ataxia and additional signs of spinal cord involvement, such as motor spasticity or sensory ataxia (see Variant 7). MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of cerebellar ataxia. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of cerebellar ataxia. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of cerebellar ataxia. MRI Head Without and With IV Contrast MRI of the head is the preferred initial imaging modality for the evaluation of patients with cerebellar ataxia.

Dizziness and Ataxia. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of cerebellar ataxia. MRI Cervical and Thoracic Spine Without IV Contrast MRI of the spine allows for evaluation of the spinal column as well as the soft tissues within and surrounding the spinal column including the spinal cord. Atrophy of the cervical spinal cord on MRI has been described in SCA type 1 (SCA1) and shown to be correlated with symptom severity, disease duration, and the number of pathologic cytosine, adenine, and guanine repeats, which serves at the genetic cause of SCA1 [78]. Similar atrophy has been reported in SCA type 7, Friedreich ataxia, and ataxia with vitamin E deficiency [79,80]. Spinal findings were associated with abnormalities of the brain parenchyma and generally not reported in isolation. Imaging of the spinal cord in other forms of cerebellar ataxia has either been reported as normal or, more often, not specifically described in the literature [81]. Spine MRI may be considered in patients with cerebellar ataxia and additional signs of spinal cord involvement, such as motor spasticity or sensory ataxia (see Variant 7). MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of cerebellar ataxia. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of cerebellar ataxia. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of cerebellar ataxia. MRI Head Without and With IV Contrast MRI of the head is the preferred initial imaging modality for the evaluation of patients with cerebellar ataxia.

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Dizziness and Ataxia

In cerebellar ataxia, morphologic changes (atrophy) and signal alterations primarily involve the cerebellum and brainstem. These findings are typically adequately evaluated on MRI without IV contrast; however, if there is concern for an inflammatory or neoplastic cause of cerebellar ataxia, contrast-enhanced imaging should be included. Advanced MRI techniques such as DWI/diffusion-tensor imaging and spectroscopy do not require contrast administration and have shown promise in detecting early changes in ataxia and may also be useful in distinguishing between some ataxia subtypes in some studies [82-84]. MRI Head Without IV Contrast MRI of the head is the preferred initial imaging modality for the evaluation of patients with cerebellar ataxia. In cerebellar ataxia, morphologic changes (atrophy) and signal alterations primarily involve the cerebellum and brainstem. These findings are typically adequately evaluated on MRI without IV contrast. Lack of contrast, however, may impair the ability to distinguish between degenerative and inflammatory/infectious causes of cerebellar ataxia. Advanced MRI techniques such as DWI/diffusion-tensor imaging and spectroscopy do not require contrast administration and have shown promise in detecting early changes in ataxia and may also be useful in distinguishing between some ataxia subtypes in some studies [82-84]. Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging. Disequilibrium refers to a sensation of imbalance, unsteadiness, or instability. Symptoms of disequilibrium may result from neurodegeneration or inflammation involving the spinocerebellar tracts, dorsal columns of the spinal Dizziness and Ataxia cord, dorsal root ganglia, or more peripheral sensory nerves. In contrast to cerebellar ataxia (see Variant 6), sensory or proprioceptive ataxia indicates loss of coordination due to loss of normal position sense and is characterized by worsening with closed eyes (eg, Romberg test).

Dizziness and Ataxia. In cerebellar ataxia, morphologic changes (atrophy) and signal alterations primarily involve the cerebellum and brainstem. These findings are typically adequately evaluated on MRI without IV contrast; however, if there is concern for an inflammatory or neoplastic cause of cerebellar ataxia, contrast-enhanced imaging should be included. Advanced MRI techniques such as DWI/diffusion-tensor imaging and spectroscopy do not require contrast administration and have shown promise in detecting early changes in ataxia and may also be useful in distinguishing between some ataxia subtypes in some studies [82-84]. MRI Head Without IV Contrast MRI of the head is the preferred initial imaging modality for the evaluation of patients with cerebellar ataxia. In cerebellar ataxia, morphologic changes (atrophy) and signal alterations primarily involve the cerebellum and brainstem. These findings are typically adequately evaluated on MRI without IV contrast. Lack of contrast, however, may impair the ability to distinguish between degenerative and inflammatory/infectious causes of cerebellar ataxia. Advanced MRI techniques such as DWI/diffusion-tensor imaging and spectroscopy do not require contrast administration and have shown promise in detecting early changes in ataxia and may also be useful in distinguishing between some ataxia subtypes in some studies [82-84]. Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging. Disequilibrium refers to a sensation of imbalance, unsteadiness, or instability. Symptoms of disequilibrium may result from neurodegeneration or inflammation involving the spinocerebellar tracts, dorsal columns of the spinal Dizziness and Ataxia cord, dorsal root ganglia, or more peripheral sensory nerves. In contrast to cerebellar ataxia (see Variant 6), sensory or proprioceptive ataxia indicates loss of coordination due to loss of normal position sense and is characterized by worsening with closed eyes (eg, Romberg test).

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Dizziness and Ataxia

SCAs may manifest with these symptoms if there is involvement of the described spinal structures. Peripheral neuropathy (ataxic neuropathy) can also be seen in various forms of SCA; however, cerebellar symptoms should be present [81]. The combination of cerebellar ataxia and sensory neuropathy, both of which can contribute to symptoms of disequilibrium, has also been described in cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome [85]. In these cases, neuroimaging is primarily directed at evaluating the coexisting central abnormalities of the cerebellum and brainstem (see Variant 6). There are also several known autoimmune sensory ataxic neuropathies, which result in symptoms of disequilibrium without cerebellar or brainstem involvement. Diagnostic confirmation of these neuropathies is generally via clinical evaluation and electrodiagnostic testing; however, targeted US has also been used to detect changes in size of the affected nerve in a small study [86]. Most of the studies in patients with SCA involve a small number of patients due to the rarity of the disease and particular mutations. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of sensory ataxia. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of sensory ataxia. CT Head Without IV Contrast There is no relevant literature regarding the use of CT head without IV contrast in the evaluation of sensory ataxia. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of sensory ataxia. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of sensory ataxia.

Dizziness and Ataxia. SCAs may manifest with these symptoms if there is involvement of the described spinal structures. Peripheral neuropathy (ataxic neuropathy) can also be seen in various forms of SCA; however, cerebellar symptoms should be present [81]. The combination of cerebellar ataxia and sensory neuropathy, both of which can contribute to symptoms of disequilibrium, has also been described in cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome [85]. In these cases, neuroimaging is primarily directed at evaluating the coexisting central abnormalities of the cerebellum and brainstem (see Variant 6). There are also several known autoimmune sensory ataxic neuropathies, which result in symptoms of disequilibrium without cerebellar or brainstem involvement. Diagnostic confirmation of these neuropathies is generally via clinical evaluation and electrodiagnostic testing; however, targeted US has also been used to detect changes in size of the affected nerve in a small study [86]. Most of the studies in patients with SCA involve a small number of patients due to the rarity of the disease and particular mutations. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of sensory ataxia. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of sensory ataxia. CT Head Without IV Contrast There is no relevant literature regarding the use of CT head without IV contrast in the evaluation of sensory ataxia. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of sensory ataxia. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of sensory ataxia.

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Dizziness and Ataxia

CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of sensory ataxia. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of sensory ataxia. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of sensory ataxia. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of sensory ataxia. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of sensory ataxia. MRI Cervical and Thoracic Spine Without and With IV Contrast MRI of the spine allows for evaluation of the spinal column as well as the soft tissues within and surrounding the spinal column including the spinal cord. Atrophy of the cervical spinal cord has been reported in several forms of degenerative ataxia, which may be a helpful diagnostic finding in patients presenting with disequilibrium [78-80]. In patients with chronic disequilibrium due to sensory ataxia and loss of proprioception that is out of proportion to Dizziness and Ataxia other sensory modalities and motor function, spine MRI is useful to evaluate the dorsal columns of the spinal cord (eg, compressive myelopathy, B12/copper deficiency, or tabes dorsalis neurosyphilis). These findings are typically adequately evaluated on MRI without IV contrast; however, if there is concern for an inflammatory or infectious neoplastic cause of sensory ataxia, contrast-enhanced imaging should be included. MRI Cervical and Thoracic Spine Without IV Contrast MRI of the spine allows for evaluation of the spinal column as well as the soft tissues within and surrounding the spinal column including the spinal cord.

Dizziness and Ataxia. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of sensory ataxia. CTA Head and Neck With IV Contrast There is no relevant literature regarding the use of CTA head and neck with IV contrast in the evaluation of sensory ataxia. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of sensory ataxia. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of sensory ataxia. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of sensory ataxia. MRI Cervical and Thoracic Spine Without and With IV Contrast MRI of the spine allows for evaluation of the spinal column as well as the soft tissues within and surrounding the spinal column including the spinal cord. Atrophy of the cervical spinal cord has been reported in several forms of degenerative ataxia, which may be a helpful diagnostic finding in patients presenting with disequilibrium [78-80]. In patients with chronic disequilibrium due to sensory ataxia and loss of proprioception that is out of proportion to Dizziness and Ataxia other sensory modalities and motor function, spine MRI is useful to evaluate the dorsal columns of the spinal cord (eg, compressive myelopathy, B12/copper deficiency, or tabes dorsalis neurosyphilis). These findings are typically adequately evaluated on MRI without IV contrast; however, if there is concern for an inflammatory or infectious neoplastic cause of sensory ataxia, contrast-enhanced imaging should be included. MRI Cervical and Thoracic Spine Without IV Contrast MRI of the spine allows for evaluation of the spinal column as well as the soft tissues within and surrounding the spinal column including the spinal cord.

69477

acrac_69477_28

Dizziness and Ataxia

Atrophy of the cervical spinal cord has been reported in several forms of degenerative ataxia, which may be a helpful diagnostic finding in patients presenting with disequilibrium [78-80]. In patients with chronic disequilibrium due to sensory ataxia and loss of proprioception that is out of proportion to other sensory modalities and motor function, spine MRI is useful to evaluate the dorsal columns of the spinal cord (eg, compressive myelopathy, B12/copper deficiency, or tabes dorsalis neurosyphilis). MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of sensory ataxia. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of sensory ataxia. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of sensory ataxia. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of sensory ataxia. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of sensory ataxia. MRI Head Without IV Contrast There is no relevant literature regarding the use of MRI head without IV contrast in the evaluation of sensory ataxia. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of isolated dizziness. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of isolated dizziness. Dizziness and Ataxia CT Head Without IV Contrast Head CT allows for evaluation of the intracranial structures; however, soft tissue contrast is inferior to MRI.

Dizziness and Ataxia. Atrophy of the cervical spinal cord has been reported in several forms of degenerative ataxia, which may be a helpful diagnostic finding in patients presenting with disequilibrium [78-80]. In patients with chronic disequilibrium due to sensory ataxia and loss of proprioception that is out of proportion to other sensory modalities and motor function, spine MRI is useful to evaluate the dorsal columns of the spinal cord (eg, compressive myelopathy, B12/copper deficiency, or tabes dorsalis neurosyphilis). MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of sensory ataxia. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of sensory ataxia. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of sensory ataxia. MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of sensory ataxia. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of sensory ataxia. MRI Head Without IV Contrast There is no relevant literature regarding the use of MRI head without IV contrast in the evaluation of sensory ataxia. CT Head With IV Contrast There is no relevant literature regarding the use of CT head with IV contrast in the evaluation of isolated dizziness. CT Head Without and With IV Contrast There is no relevant literature regarding the use of CT head without and with IV contrast in the evaluation of isolated dizziness. Dizziness and Ataxia CT Head Without IV Contrast Head CT allows for evaluation of the intracranial structures; however, soft tissue contrast is inferior to MRI.

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Dizziness and Ataxia

This is especially true of lesions in the posterior cranial fossa, which are more likely to cause dizziness [2]. In 29,510 patients with isolated dizziness presenting to a large academic emergency department, the overall diagnostic yield of CT is very low (<1%) [4]. In multiple studies, CT has demonstrated a high negative predictive value of approximately 90% but a low sensitivity (20%-40%) for detecting a causative etiology [2,3]. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of isolated dizziness. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of isolated dizziness. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of isolated dizziness. CTA Head and Neck With IV Contrast CTA allows for evaluation of the course and luminal caliber of the studied arteries. CTA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. CTA of the head and neck has been shown to have a low overall diagnostic yield of approximately 3% in the setting of isolated dizziness. CTA also did not contribute any additional information over noncontrast head CT in this clinical setting. Overall, CTA in isolated dizziness was shown to have a sensitivity of 14%, specificity of 98%, positive predicative value of 40% and negative predicative value of 92% [3]. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of isolated dizziness. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of isolated dizziness.

Dizziness and Ataxia. This is especially true of lesions in the posterior cranial fossa, which are more likely to cause dizziness [2]. In 29,510 patients with isolated dizziness presenting to a large academic emergency department, the overall diagnostic yield of CT is very low (<1%) [4]. In multiple studies, CT has demonstrated a high negative predictive value of approximately 90% but a low sensitivity (20%-40%) for detecting a causative etiology [2,3]. CT Temporal Bone With IV Contrast There is no relevant literature regarding the use of CT temporal bone with IV contrast in the evaluation of isolated dizziness. CT Temporal Bone Without and With IV Contrast There is no relevant literature regarding the use of CT temporal bone without and with IV contrast in the evaluation of isolated dizziness. CT Temporal Bone Without IV Contrast There is no relevant literature regarding the use of CT temporal bone without IV contrast in the evaluation of isolated dizziness. CTA Head and Neck With IV Contrast CTA allows for evaluation of the course and luminal caliber of the studied arteries. CTA can also detect luminal filling defects, which may include thrombus, embolus, atherosclerotic plaque, dissection flap, or vascular web. CTA of the head and neck has been shown to have a low overall diagnostic yield of approximately 3% in the setting of isolated dizziness. CTA also did not contribute any additional information over noncontrast head CT in this clinical setting. Overall, CTA in isolated dizziness was shown to have a sensitivity of 14%, specificity of 98%, positive predicative value of 40% and negative predicative value of 92% [3]. MRA Head and Neck With IV Contrast There is no relevant literature regarding the use of MRA head and neck with IV contrast in the evaluation of isolated dizziness. MRA Head and Neck Without and With IV Contrast There is no relevant literature regarding the use of MRA head and neck without and with IV contrast in the evaluation of isolated dizziness.

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acrac_69477_30

Dizziness and Ataxia

MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of isolated dizziness. Dizziness and Ataxia MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of isolated dizziness. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of isolated dizziness. MRI Head Without IV Contrast MRI allows for detailed evaluation of the intracranial structures with improved soft tissue resolution when compared with CT. Despite this, the diagnostic yield of noncontrast MRI head in patients presenting to the emergency department with isolated dizziness is low (~4%).

Dizziness and Ataxia. MRA Head and Neck Without IV Contrast There is no relevant literature regarding the use of MRA head and neck without IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine with IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine Without and With IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without and with IV contrast in the evaluation of isolated dizziness. MRI Cervical and Thoracic Spine Without IV Contrast There is no relevant literature regarding the use of MRI cervical and thoracic spine without IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal With IV Contrast There is no relevant literature regarding the use of MRI head and IAC with IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal Without and With IV Contrast There is no relevant literature regarding the use of MRI head and IAC without and with IV contrast in the evaluation of isolated dizziness. MRI Head and Internal Auditory Canal Without IV Contrast There is no relevant literature regarding the use of MRI head and IAC without IV contrast in the evaluation of isolated dizziness. Dizziness and Ataxia MRI Head With IV Contrast There is no relevant literature regarding the use of MRI head with IV contrast in the evaluation of isolated dizziness. MRI Head Without and With IV Contrast There is no relevant literature regarding the use of MRI head without and with IV contrast in the evaluation of isolated dizziness. MRI Head Without IV Contrast MRI allows for detailed evaluation of the intracranial structures with improved soft tissue resolution when compared with CT. Despite this, the diagnostic yield of noncontrast MRI head in patients presenting to the emergency department with isolated dizziness is low (~4%).

69477

acrac_69446_0

Acute Respiratory Illness in Immunocompetent Patients

Introduction/Background Acute respiratory illness (ARI) is defined as one or more of the following symptoms: cough, sputum production, chest pain, or dyspnea (with or without fever), usually in the setting of suspected respiratory infection. ARI is a major public health issue, being one of the most common reasons for doctor office or emergency department (ED) visits. Cough, chest pain, and dyspnea account for 3 of the top 10 presenting symptoms during ED visits [1]. Most cases of ARI are attributable to infection, and the major diagnostic dilemma for patients with ARI is distinguishing patients with self-limited viral infection from those with a bacterial pneumonia (PNA), such as community-acquired PNA. In 2014, PNA (combined with influenza) accounted for the eighth most common cause of death in the United States [2]. The primary role of imaging in patients with ARI is to aid in the diagnosis or exclusion of PNA. By helping to identify the subset of ARI patients with PNA, imaging helps separate patients who would benefit from antibiotic therapy from those who would not. This increases the chance that patients with PNA receive appropriate therapy and reduces the risks associated with inappropriate use of antibiotics in patients with viral causes of ARI. The need for imaging in the ARI patient may depend on a number of factors, which can include severity of illness; presence of fever, leukocytosis, or hypoxemia; clinical history; physical examination findings; patient age; and the presence of other risk factors. Not all studies concur as to which patients with ARI should have an initial imaging study. While chest radiographs have a long track record, they do have lower sensitivity for PNA relative to other imaging modalities such as CT. Self et al [5] performed an observational cross-sectional multicenter study that enrolled 3,423 ED patients presenting with ARI. This is one of the largest studies comparing chest radiographs and CT in the ED setting.

Acute Respiratory Illness in Immunocompetent Patients. Introduction/Background Acute respiratory illness (ARI) is defined as one or more of the following symptoms: cough, sputum production, chest pain, or dyspnea (with or without fever), usually in the setting of suspected respiratory infection. ARI is a major public health issue, being one of the most common reasons for doctor office or emergency department (ED) visits. Cough, chest pain, and dyspnea account for 3 of the top 10 presenting symptoms during ED visits [1]. Most cases of ARI are attributable to infection, and the major diagnostic dilemma for patients with ARI is distinguishing patients with self-limited viral infection from those with a bacterial pneumonia (PNA), such as community-acquired PNA. In 2014, PNA (combined with influenza) accounted for the eighth most common cause of death in the United States [2]. The primary role of imaging in patients with ARI is to aid in the diagnosis or exclusion of PNA. By helping to identify the subset of ARI patients with PNA, imaging helps separate patients who would benefit from antibiotic therapy from those who would not. This increases the chance that patients with PNA receive appropriate therapy and reduces the risks associated with inappropriate use of antibiotics in patients with viral causes of ARI. The need for imaging in the ARI patient may depend on a number of factors, which can include severity of illness; presence of fever, leukocytosis, or hypoxemia; clinical history; physical examination findings; patient age; and the presence of other risk factors. Not all studies concur as to which patients with ARI should have an initial imaging study. While chest radiographs have a long track record, they do have lower sensitivity for PNA relative to other imaging modalities such as CT. Self et al [5] performed an observational cross-sectional multicenter study that enrolled 3,423 ED patients presenting with ARI. This is one of the largest studies comparing chest radiographs and CT in the ED setting.

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Acute Respiratory Illness in Immunocompetent Patients

Using CT as a gold standard, chest radiograph test characteristics for detection of pulmonary opacities included: sensitivity of 43.5%, specificity of 93.0%, positive predictive value of 26.9%, and negative predictive value of 96.5%. Conversely, other studies, such as Haga et al [6], demonstrate sensitivities as high as 91% for chest radiographs relative to CT for diagnosing PNA. Despite inconsistent data regarding the aMayo Clinic, Phoenix, Arizona. bPanel Chair, National Jewish Health, Denver, Colorado. cMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. dThe University of Texas MD Anderson Cancer Center, Houston, Texas. eUniversity of Southern California, Los Angeles, California. fSouthern Illinois University School of Medicine, Springfield, Illinois; The Society of Thoracic Surgeons. gThe University of Texas MD Anderson Cancer Center, Houston, Texas. hUniversity of Iowa, Iowa City, Iowa; The Society of Thoracic Surgeons. iVanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians. jMayo Clinic, Jacksonville, Florida. kColumbia University Medical Center New York and Temple University Health System, Philadelphia, Pennsylvania. lSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. 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: publications@acr.org sensitivity of chest radiographs for PNA, it still plays a role as the primary modality for making or excluding the diagnosis of PNA in patients presenting with ARI.

Acute Respiratory Illness in Immunocompetent Patients. Using CT as a gold standard, chest radiograph test characteristics for detection of pulmonary opacities included: sensitivity of 43.5%, specificity of 93.0%, positive predictive value of 26.9%, and negative predictive value of 96.5%. Conversely, other studies, such as Haga et al [6], demonstrate sensitivities as high as 91% for chest radiographs relative to CT for diagnosing PNA. Despite inconsistent data regarding the aMayo Clinic, Phoenix, Arizona. bPanel Chair, National Jewish Health, Denver, Colorado. cMassachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. dThe University of Texas MD Anderson Cancer Center, Houston, Texas. eUniversity of Southern California, Los Angeles, California. fSouthern Illinois University School of Medicine, Springfield, Illinois; The Society of Thoracic Surgeons. gThe University of Texas MD Anderson Cancer Center, Houston, Texas. hUniversity of Iowa, Iowa City, Iowa; The Society of Thoracic Surgeons. iVanderbilt University Medical Center, Nashville, Tennessee; American College of Chest Physicians. jMayo Clinic, Jacksonville, Florida. kColumbia University Medical Center New York and Temple University Health System, Philadelphia, Pennsylvania. lSpecialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. 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: publications@acr.org sensitivity of chest radiographs for PNA, it still plays a role as the primary modality for making or excluding the diagnosis of PNA in patients presenting with ARI.

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acrac_69446_2

Acute Respiratory Illness in Immunocompetent Patients

CT Chest The major advantage of CT in the setting of ARI is its increased sensitivity relative to chest radiographs for the diagnosis of PNA. In comparative studies in which patients with PNA received both CT and chest radiograph, the rate of PNA missed by chest radiographs but detected by CT has been highly variable, ranging from 9.4% [6] to 56.5% [5]. CT has also been shown to be more specific than chest radiographs for the diagnosis of PNA [5,7]. US Chest There is a growing body of literature suggesting that bedside lung ultrasound (US) can be a useful tool in the diagnosis and management of PNA [8-12]. Nazerian et al [10] evaluated the accuracy of US relative to CT on 285 patients who had at least one respiratory complaint for which the ED physician ordered a CT. CT was considered positive if at least one typical consolidation was detected. US identified at least one consolidation in 81 patients versus 87 for CT. Relative to CT; US had a sensitivity of 82.8% and a specificity of 95.5%. While this study demonstrates impressive performance of US for detecting pulmonary consolidation, the study was limited by the fact that patients were enrolled based on whether or not they had a CT ordered rather than clinical suspicion of PNA. US is of limited value in patients with subcutaneous emphysema, in the setting of obesity/thick chest wall, and in patients with limited chest wall access related to bandages, prosthetic material, and skin disorders [13]. In addition, US has difficulty identifying PNAs that are not adjacent to the pleura. This limits its effectiveness for detecting more central infections, especially when there is aerated lung intervening between the transducer and the PNA [8,10,11]. MRI Chest Our literature search identified one recently published article evaluating the use of MRI in the setting of ARI in immunocompetent adult patients [14]. The study suggests a sensitivity for PNA that approaches that of CT.

Acute Respiratory Illness in Immunocompetent Patients. CT Chest The major advantage of CT in the setting of ARI is its increased sensitivity relative to chest radiographs for the diagnosis of PNA. In comparative studies in which patients with PNA received both CT and chest radiograph, the rate of PNA missed by chest radiographs but detected by CT has been highly variable, ranging from 9.4% [6] to 56.5% [5]. CT has also been shown to be more specific than chest radiographs for the diagnosis of PNA [5,7]. US Chest There is a growing body of literature suggesting that bedside lung ultrasound (US) can be a useful tool in the diagnosis and management of PNA [8-12]. Nazerian et al [10] evaluated the accuracy of US relative to CT on 285 patients who had at least one respiratory complaint for which the ED physician ordered a CT. CT was considered positive if at least one typical consolidation was detected. US identified at least one consolidation in 81 patients versus 87 for CT. Relative to CT; US had a sensitivity of 82.8% and a specificity of 95.5%. While this study demonstrates impressive performance of US for detecting pulmonary consolidation, the study was limited by the fact that patients were enrolled based on whether or not they had a CT ordered rather than clinical suspicion of PNA. US is of limited value in patients with subcutaneous emphysema, in the setting of obesity/thick chest wall, and in patients with limited chest wall access related to bandages, prosthetic material, and skin disorders [13]. In addition, US has difficulty identifying PNAs that are not adjacent to the pleura. This limits its effectiveness for detecting more central infections, especially when there is aerated lung intervening between the transducer and the PNA [8,10,11]. MRI Chest Our literature search identified one recently published article evaluating the use of MRI in the setting of ARI in immunocompetent adult patients [14]. The study suggests a sensitivity for PNA that approaches that of CT.

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acrac_69446_3

Acute Respiratory Illness in Immunocompetent Patients

Over the past 10 years, the utility of MRI for detecting PNA has been studied more extensively in pediatric and immunocompromised patient populations; these studies demonstrated a similar favorable sensitivity of MRI for detecting PNA [15-20]. PET/CT Our literature search failed to identify any articles published within the past 10 years that justify the use of PET/CT in the initial workup of ARI in the immunocompetent patient. The usefulness of this imaging modality is not discussed in any of the clinical variants because of lack of evidence. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA. US Chest Many of the studies evaluating the potential of US to diagnose PNA in the ED are aimed at assessing the diagnostic accuracy of US for PNA using either CT or discharge diagnosis as the gold standard [8-11]. Many of these patients were sick enough to warrant CT or admission, representing a subset of patients with a relatively high pretest probability of PNA. The current literature does not suggest a routine role for initial imaging with US in a clinical variant with a low pretest probability of PNA. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA. Variant 2: Acute respiratory illnesses in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Initial imaging. Radiography Chest In a series of 300 patients with acute cough illness, Aagaard et al [29] found that a chest radiograph was not always obtained for patients with a high pretest probability of PNA; they infer that when the clinical probability of PNA exceeds a certain level, a negative radiograph would not alter treatment decisions.

Acute Respiratory Illness in Immunocompetent Patients. Over the past 10 years, the utility of MRI for detecting PNA has been studied more extensively in pediatric and immunocompromised patient populations; these studies demonstrated a similar favorable sensitivity of MRI for detecting PNA [15-20]. PET/CT Our literature search failed to identify any articles published within the past 10 years that justify the use of PET/CT in the initial workup of ARI in the immunocompetent patient. The usefulness of this imaging modality is not discussed in any of the clinical variants because of lack of evidence. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA. US Chest Many of the studies evaluating the potential of US to diagnose PNA in the ED are aimed at assessing the diagnostic accuracy of US for PNA using either CT or discharge diagnosis as the gold standard [8-11]. Many of these patients were sick enough to warrant CT or admission, representing a subset of patients with a relatively high pretest probability of PNA. The current literature does not suggest a routine role for initial imaging with US in a clinical variant with a low pretest probability of PNA. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA. Variant 2: Acute respiratory illnesses in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Initial imaging. Radiography Chest In a series of 300 patients with acute cough illness, Aagaard et al [29] found that a chest radiograph was not always obtained for patients with a high pretest probability of PNA; they infer that when the clinical probability of PNA exceeds a certain level, a negative radiograph would not alter treatment decisions.

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acrac_69446_4

Acute Respiratory Illness in Immunocompetent Patients

A series by Basi et al [30] that included 2,706 patients hospitalized with community-acquired PNA similarly showed that about one- third had radiographs initially interpreted as negative for PNA, with minimal change in this interpretation on retrospective review of a random subgroup. These two studies call into question the usefulness of radiographs in patients with a high pretest probability of PNA. That being said, data from many of the studies that suggested the low utility of chest radiographs in Variant 1 also demonstrate a relatively high incidence of PNA on chest radiographs in patients with physical examination findings, abnormal vital signs, leukocytosis, or other risk factors, such as advanced age [21-25]. For example, Benacerraf et al [21] reported that a subgroup of patients <40 years of age with an abnormal physical examination were about six times more likely to have an acute finding on their chest radiograph. Speets et al [31] evaluated 192 patients with a clinical suspicion of PNA by general practitioners and found that the post- test probability of PNA was changed by chest radiographic results in 53% of patients, with a 47% decrease in probability and a 6% increase in probability. Patient management changed following a chest radiograph in 69% of patients. These data would seem to support the routine use of chest radiographs to confirm the diagnosis of PNA in this clinical variant. Current IDSA/ATS guidelines also support this approach [4]. In a population of ED patients who received a chest radiograph for respiratory complaints, Heckerling [22] found that over 75% of the patients with dementia had PNA on their chest radiograph regardless of physical examination findings. The authors postulate that aspiration related to altered level of consciousness and compromised epiglottic closure could account for the high prevalence of PNA amongst these patients.

Acute Respiratory Illness in Immunocompetent Patients. A series by Basi et al [30] that included 2,706 patients hospitalized with community-acquired PNA similarly showed that about one- third had radiographs initially interpreted as negative for PNA, with minimal change in this interpretation on retrospective review of a random subgroup. These two studies call into question the usefulness of radiographs in patients with a high pretest probability of PNA. That being said, data from many of the studies that suggested the low utility of chest radiographs in Variant 1 also demonstrate a relatively high incidence of PNA on chest radiographs in patients with physical examination findings, abnormal vital signs, leukocytosis, or other risk factors, such as advanced age [21-25]. For example, Benacerraf et al [21] reported that a subgroup of patients <40 years of age with an abnormal physical examination were about six times more likely to have an acute finding on their chest radiograph. Speets et al [31] evaluated 192 patients with a clinical suspicion of PNA by general practitioners and found that the post- test probability of PNA was changed by chest radiographic results in 53% of patients, with a 47% decrease in probability and a 6% increase in probability. Patient management changed following a chest radiograph in 69% of patients. These data would seem to support the routine use of chest radiographs to confirm the diagnosis of PNA in this clinical variant. Current IDSA/ATS guidelines also support this approach [4]. In a population of ED patients who received a chest radiograph for respiratory complaints, Heckerling [22] found that over 75% of the patients with dementia had PNA on their chest radiograph regardless of physical examination findings. The authors postulate that aspiration related to altered level of consciousness and compromised epiglottic closure could account for the high prevalence of PNA amongst these patients.

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acrac_69446_5

Acute Respiratory Illness in Immunocompetent Patients

Although there is a paucity of data to support this, it would be logical to include other patients with organic brain disease, such as Acute Respiratory Illness in Immunocompetent Patients stroke and delirium, in addition to dementia, as also having a high pretest probability of PNA despite otherwise negative physical examination findings and normal vital signs. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA. The role of CT for patients with a negative or equivocal initial chest radiograph is discussed in Variant 3. US Chest One prospective multicenter study performed by Reissig et al [11] enrolled 362 patients with abnormal vital signs or physical examination findings in addition to ARI symptoms. Patients received a two-view chest radiograph and a US. In cases in which the chest radiograph was negative or inconclusive and the US was positive, a chest CT was performed. This study demonstrated US sensitivity and specificity of 93.4% and 97.7%, respectively; however, these values are almost certainly overestimated because of the fact that a chest radiograph, rather than CT, was used as the reference standard in all cases except those in which there was discordance between an inconclusive or negative chest radiograph and a positive US. Bourcier et al [8] studied US and chest radiographs in a similar patient population. The final diagnosis was based on a chart review made by an independent expert and included clinical findings, labs, chest radiographs, and CT, if available. US in this study again demonstrated superior sensitivity for PNA relative to chest radiographs. Like Reissig et al, this study was limited by the lack of a consistent end point. Even with these limitations, the results of these studies suggest bedside US can be a useful tool for evaluating certain patients with a high pretest probability of PNA.

Acute Respiratory Illness in Immunocompetent Patients. Although there is a paucity of data to support this, it would be logical to include other patients with organic brain disease, such as Acute Respiratory Illness in Immunocompetent Patients stroke and delirium, in addition to dementia, as also having a high pretest probability of PNA despite otherwise negative physical examination findings and normal vital signs. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA. The role of CT for patients with a negative or equivocal initial chest radiograph is discussed in Variant 3. US Chest One prospective multicenter study performed by Reissig et al [11] enrolled 362 patients with abnormal vital signs or physical examination findings in addition to ARI symptoms. Patients received a two-view chest radiograph and a US. In cases in which the chest radiograph was negative or inconclusive and the US was positive, a chest CT was performed. This study demonstrated US sensitivity and specificity of 93.4% and 97.7%, respectively; however, these values are almost certainly overestimated because of the fact that a chest radiograph, rather than CT, was used as the reference standard in all cases except those in which there was discordance between an inconclusive or negative chest radiograph and a positive US. Bourcier et al [8] studied US and chest radiographs in a similar patient population. The final diagnosis was based on a chart review made by an independent expert and included clinical findings, labs, chest radiographs, and CT, if available. US in this study again demonstrated superior sensitivity for PNA relative to chest radiographs. Like Reissig et al, this study was limited by the lack of a consistent end point. Even with these limitations, the results of these studies suggest bedside US can be a useful tool for evaluating certain patients with a high pretest probability of PNA.

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acrac_69446_6

Acute Respiratory Illness in Immunocompetent Patients

MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA. The role of MRI for patients with a negative or equivocal initial chest radiograph is discussed in Variant 3. Variant 3: Acute respiratory illness in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors and negative or equivocal initial chest radiograph. Next imaging study. Radiography Chest There is no indication in the literature to suggest that repeat chest radiograph serves any significant role in imaging patients with a high pretest probability of PNA and a negative or equivocal initial chest radiograph. CT Chest There are several studies that assess the use of CT as a subsequent study in patients who have already had a chest radiograph. One of the larger reviews by Hayden et al [32] identified 97 of 1,057 ED patients with a diagnosis of PNA who had both a chest radiograph and CT. Within this selected group, 26 patients (27%) had PNA that was not detected with chest radiograph but was subsequently detected with CT. Maughan et al [33], in a retrospective review designed to evaluate the false-negative rate of chest radiographs in ED patients with PNA, identified 49 cases (11.4%) where PNA was diagnosed with CT, despite a normal chest radiograph. Haga et al [6] also demonstrated the improved ability of CT to assess the severity of PNA relative to chest radiographs. Bilateral PNA, as detected by CT, was associated with a higher degree of mortality. The presence of multilobar opacities, which is a minor criterion in the IDSA/ATS guidelines for intensive care unit admission, is best assessed with CT [4]. One of the more recent studies assessing the use of CT for ED patients with suspected PNA is Claessens et al [7], a prospective multicenter study that enrolled 319 patients.

Acute Respiratory Illness in Immunocompetent Patients. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA. The role of MRI for patients with a negative or equivocal initial chest radiograph is discussed in Variant 3. Variant 3: Acute respiratory illness in immunocompetent patients with positive physical examination, abnormal vital signs, organic brain disease, or other risk factors and negative or equivocal initial chest radiograph. Next imaging study. Radiography Chest There is no indication in the literature to suggest that repeat chest radiograph serves any significant role in imaging patients with a high pretest probability of PNA and a negative or equivocal initial chest radiograph. CT Chest There are several studies that assess the use of CT as a subsequent study in patients who have already had a chest radiograph. One of the larger reviews by Hayden et al [32] identified 97 of 1,057 ED patients with a diagnosis of PNA who had both a chest radiograph and CT. Within this selected group, 26 patients (27%) had PNA that was not detected with chest radiograph but was subsequently detected with CT. Maughan et al [33], in a retrospective review designed to evaluate the false-negative rate of chest radiographs in ED patients with PNA, identified 49 cases (11.4%) where PNA was diagnosed with CT, despite a normal chest radiograph. Haga et al [6] also demonstrated the improved ability of CT to assess the severity of PNA relative to chest radiographs. Bilateral PNA, as detected by CT, was associated with a higher degree of mortality. The presence of multilobar opacities, which is a minor criterion in the IDSA/ATS guidelines for intensive care unit admission, is best assessed with CT [4]. One of the more recent studies assessing the use of CT for ED patients with suspected PNA is Claessens et al [7], a prospective multicenter study that enrolled 319 patients.

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Acute Respiratory Illness in Immunocompetent Patients

The inclusion criteria included a mix of ARI symptoms and abnormal vital signs or physical examination findings. All patients received a chest radiograph and a CT within 4 hours of presentation. Chest radiographs identified opacities consistent with PNA in 188 of 319 (59%) patients. CT revealed PNA in 40 (33%) of the 131 patients without opacity on chest radiographs and excluded PNA in 56 (29.8%) of the 188 patients with opacities on chest radiographs. Because of CT, antibiotics were initiated in 51 (16%) patients and discontinued in 29 (9%) patients. CT findings also resulted in 22 additional hospitalizations and 23 discharges. The available data clearly show that CT is more accurate than chest radiographs for the diagnosis of PNA. In most cases a combination of vital signs and physical examination findings, along with judicious use of chest radiographs, is deemed sufficient for diagnosing or excluding PNA. However, in certain patients, such as those who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening (such as patients with advanced age, unreliable follow-up, or significant comorbidities), chest CT may be warranted when initial chest radiograph is negative or equivocal [24,32,34]. The IDSA/ATS consensus guidelines consider CT a reasonable alternative to empiric antibiotic therapy with follow-up chest radiographs when there is a high clinical suspicion of PNA [4]. Given the difficulty of obtaining an accurate history and physical examination and the high incidence of PNA in patients with organic brain disease, CT is a reasonable alternative to empiric treatment antibiotics in the setting of a negative or equivocal initial chest radiograph. US Chest Studies performed by Reissig et al [11] and Bourcier et al [8] suggest that US has a higher sensitivity than radiographs for PNA, implying that US may add value in cases in which PNA is suspected but initial chest radiographs are negative or equivocal.

Acute Respiratory Illness in Immunocompetent Patients. The inclusion criteria included a mix of ARI symptoms and abnormal vital signs or physical examination findings. All patients received a chest radiograph and a CT within 4 hours of presentation. Chest radiographs identified opacities consistent with PNA in 188 of 319 (59%) patients. CT revealed PNA in 40 (33%) of the 131 patients without opacity on chest radiographs and excluded PNA in 56 (29.8%) of the 188 patients with opacities on chest radiographs. Because of CT, antibiotics were initiated in 51 (16%) patients and discontinued in 29 (9%) patients. CT findings also resulted in 22 additional hospitalizations and 23 discharges. The available data clearly show that CT is more accurate than chest radiographs for the diagnosis of PNA. In most cases a combination of vital signs and physical examination findings, along with judicious use of chest radiographs, is deemed sufficient for diagnosing or excluding PNA. However, in certain patients, such as those who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening (such as patients with advanced age, unreliable follow-up, or significant comorbidities), chest CT may be warranted when initial chest radiograph is negative or equivocal [24,32,34]. The IDSA/ATS consensus guidelines consider CT a reasonable alternative to empiric antibiotic therapy with follow-up chest radiographs when there is a high clinical suspicion of PNA [4]. Given the difficulty of obtaining an accurate history and physical examination and the high incidence of PNA in patients with organic brain disease, CT is a reasonable alternative to empiric treatment antibiotics in the setting of a negative or equivocal initial chest radiograph. US Chest Studies performed by Reissig et al [11] and Bourcier et al [8] suggest that US has a higher sensitivity than radiographs for PNA, implying that US may add value in cases in which PNA is suspected but initial chest radiographs are negative or equivocal.

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Acute Respiratory Illness in Immunocompetent Patients

Nazerian et al [10] evaluated the accuracy of US relative to CT on 285 patients who had at least one respiratory complaint for which the ED physician ordered a CT. In the subgroup of patients who also had a chest radiograph, US demonstrated sensitivity and specificity of 81.4% and 94.2%, respectively, versus 64.3% and 90% for chest radiographs. The increased sensitivity of US implies additional value of US in cases in which the initial chest radiograph is discordant with clinical suspicion; however, the study was limited by the fact that patients were enrolled based on whether or not they had a CT ordered, rather than clinical suspicion of PNA. Given the difficulty of obtaining an accurate history and physical examination as well as the high incidence of PNA in patients with organic brain disease, US is a reasonable alternative to empiric treatment with antibiotics in the setting of a negative or equivocal initial chest radiograph. The ability of the patient to tolerate an US examination, presence of an adequate acoustic window, and the limited ability of US to detect all but peripheral PNAs would be additional considerations. MRI Chest Syrjala et al [14] compared the sensitivity and specificity of noncontrast MRI (respiratory-triggered T2 fast spin- echo) to chest radiographs using CT as a gold standard. The patient population consisted of immunocompetent adult ambulatory outpatients with ARI who were febrile and symptomatic for <7 days. CT detected 32 cases of PNA out of 77 prospectively enrolled patients. MRI detected 30/32 cases (sensitivity 94%) with no false-positives (specificity 98%), whereas chest radiographs only detected 23 cases (sensitivity 72%) and gave 4 false-positive results (specificity 91%). These data suggest a potential role for MRI in detecting PNA in situations where initial chest radiographs findings are negative or equivocal; however, the sensitivity of CT appears to be slightly superior to that of MRI.

Acute Respiratory Illness in Immunocompetent Patients. Nazerian et al [10] evaluated the accuracy of US relative to CT on 285 patients who had at least one respiratory complaint for which the ED physician ordered a CT. In the subgroup of patients who also had a chest radiograph, US demonstrated sensitivity and specificity of 81.4% and 94.2%, respectively, versus 64.3% and 90% for chest radiographs. The increased sensitivity of US implies additional value of US in cases in which the initial chest radiograph is discordant with clinical suspicion; however, the study was limited by the fact that patients were enrolled based on whether or not they had a CT ordered, rather than clinical suspicion of PNA. Given the difficulty of obtaining an accurate history and physical examination as well as the high incidence of PNA in patients with organic brain disease, US is a reasonable alternative to empiric treatment with antibiotics in the setting of a negative or equivocal initial chest radiograph. The ability of the patient to tolerate an US examination, presence of an adequate acoustic window, and the limited ability of US to detect all but peripheral PNAs would be additional considerations. MRI Chest Syrjala et al [14] compared the sensitivity and specificity of noncontrast MRI (respiratory-triggered T2 fast spin- echo) to chest radiographs using CT as a gold standard. The patient population consisted of immunocompetent adult ambulatory outpatients with ARI who were febrile and symptomatic for <7 days. CT detected 32 cases of PNA out of 77 prospectively enrolled patients. MRI detected 30/32 cases (sensitivity 94%) with no false-positives (specificity 98%), whereas chest radiographs only detected 23 cases (sensitivity 72%) and gave 4 false-positive results (specificity 91%). These data suggest a potential role for MRI in detecting PNA in situations where initial chest radiographs findings are negative or equivocal; however, the sensitivity of CT appears to be slightly superior to that of MRI.

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acrac_69446_9

Acute Respiratory Illness in Immunocompetent Patients

Variant 4: Acute respiratory illnesses in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study. Radiography Chest Chest radiographs are a useful initial imaging modality for complicated PNA, but they are inferior to other modalities for evaluating the pleura, for guiding interventions, or for assessing an opacity that has been refractory to therapy. CT Chest In severe cases of PNA, CT can demonstrate the overall extent of disease, which may provide important prognostic information [6]. CT can also demonstrate necrotizing PNA and abscess formation long before the findings become visible on a chest radiograph. The use of intravenous contrast can increase the conspicuity of empyemas and other pleural complications. CT can also serve as a guide for pleural drainage or localization of an appropriate site for biopsy [35]. CT is the modality of choice for evaluating a persistent opacity. Its superior contrast resolution allows it to detect obstructing masses, delineate lesions, such as sequestrations, and even characterize patterns of parenchymal disease, such that a particular etiology, such as organizing PNA or mycobacterial infection, can sometimes be suggested. US Chest US may be a useful adjunct for the evaluation of parapneumonic effusions as it is superior to chest radiographs for demonstrating pleural thickening and adhesions. US is superior to noncontrast CT for detecting septations in Acute Respiratory Illness in Immunocompetent Patients complex effusions. US can also be used to guide PNA-related interventions, such as biopsy, thoracentesis, and thoracostomy tube placement [36]. MRI Chest Our search failed to identify any studies evaluating the role of MRI in this clinical scenario. The study population examined by Syrjala et al [14] did not include any patients with parapneumonic effusion or empyema.

Acute Respiratory Illness in Immunocompetent Patients. Variant 4: Acute respiratory illnesses in immunocompetent patients with pneumonia complicated by suspected parapneumonic effusion or abscess on initial chest radiograph. Next imaging study. Radiography Chest Chest radiographs are a useful initial imaging modality for complicated PNA, but they are inferior to other modalities for evaluating the pleura, for guiding interventions, or for assessing an opacity that has been refractory to therapy. CT Chest In severe cases of PNA, CT can demonstrate the overall extent of disease, which may provide important prognostic information [6]. CT can also demonstrate necrotizing PNA and abscess formation long before the findings become visible on a chest radiograph. The use of intravenous contrast can increase the conspicuity of empyemas and other pleural complications. CT can also serve as a guide for pleural drainage or localization of an appropriate site for biopsy [35]. CT is the modality of choice for evaluating a persistent opacity. Its superior contrast resolution allows it to detect obstructing masses, delineate lesions, such as sequestrations, and even characterize patterns of parenchymal disease, such that a particular etiology, such as organizing PNA or mycobacterial infection, can sometimes be suggested. US Chest US may be a useful adjunct for the evaluation of parapneumonic effusions as it is superior to chest radiographs for demonstrating pleural thickening and adhesions. US is superior to noncontrast CT for detecting septations in Acute Respiratory Illness in Immunocompetent Patients complex effusions. US can also be used to guide PNA-related interventions, such as biopsy, thoracentesis, and thoracostomy tube placement [36]. MRI Chest Our search failed to identify any studies evaluating the role of MRI in this clinical scenario. The study population examined by Syrjala et al [14] did not include any patients with parapneumonic effusion or empyema.

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acrac_69446_10

Acute Respiratory Illness in Immunocompetent Patients

However, MRI has been shown to be at least as sensitive as CT for detecting pleural effusions in immunocompromised patients and is superior to CT for detecting pleural adhesions/loculations [16]. Variant 5: Acute asthma exacerbation in immunocompetent patients, uncomplicated (no suspicion of pneumonia or pneumothorax). Initial imaging. Radiography Chest The incidence of PNA is exceedingly low in patients presenting with an uncomplicated asthma exacerbation. Heckerling [22] reported <2% of asthmatic patients as having pneumonic opacities. Findley and Sahn [37] observed that 99% of their patients either had normal chest radiograph examinations or showed only slightly prominent markings or hyperinflation. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. Variant 6: Acute asthma exacerbation in immunocompetent patients, complicated (suspected pneumonia or pneumothorax). Initial imaging. Radiography Chest Use of chest radiographs in patients with asthma exacerbation is controversial. Petheram et al [38] found clinically important radiographic findings in 9% of their patients and concluded that a chest radiograph is indicated. However, the incidence of PNA in patients presenting with an asthma exacerbation is low [22,37].

Acute Respiratory Illness in Immunocompetent Patients. However, MRI has been shown to be at least as sensitive as CT for detecting pleural effusions in immunocompromised patients and is superior to CT for detecting pleural adhesions/loculations [16]. Variant 5: Acute asthma exacerbation in immunocompetent patients, uncomplicated (no suspicion of pneumonia or pneumothorax). Initial imaging. Radiography Chest The incidence of PNA is exceedingly low in patients presenting with an uncomplicated asthma exacerbation. Heckerling [22] reported <2% of asthmatic patients as having pneumonic opacities. Findley and Sahn [37] observed that 99% of their patients either had normal chest radiograph examinations or showed only slightly prominent markings or hyperinflation. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with an acute asthma exacerbation. Variant 6: Acute asthma exacerbation in immunocompetent patients, complicated (suspected pneumonia or pneumothorax). Initial imaging. Radiography Chest Use of chest radiographs in patients with asthma exacerbation is controversial. Petheram et al [38] found clinically important radiographic findings in 9% of their patients and concluded that a chest radiograph is indicated. However, the incidence of PNA in patients presenting with an asthma exacerbation is low [22,37].

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Acute Respiratory Illness in Immunocompetent Patients

Findley and Sahn [37] recommended chest radiographs only when PNA or pneumothorax is suspected. White et al [39] found significant chest radiograph abnormalities in 34% of adults whose asthma exacerbation warranted hospital admission. CT Chest Although our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of patients with a high pretest probability of PNA presenting with an acute asthma exacerbation, patients who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening may warrant a CT if the chest radiograph is negative or equivocal. Chest radiographs are usually sufficient to diagnose pneumothorax. CT should be reserved for patients who require additional evaluation of their pneumothorax to look for an underlying cause. US Chest US may be a reasonable alternative to chest radiographs to identify PNA [8-12] and pneumothorax [13]. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with an acute asthma exacerbation. Acute Respiratory Illness in Immunocompetent Patients Variant 7: Acute COPD exacerbation in immunocompetent patients, uncomplicated (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Initial imaging. Radiography Chest The ATS defines a chronic obstructive pulmonary disease (COPD) flare as an acute worsening of COPD symptoms. Sherman et al [40] studied the usefulness of chest radiographs in 242 patients with acute exacerbations of COPD. Of this group, 135 patients (56%) had asthma, and 107 (44%) had emphysema and chronic bronchitis. Chest radiographs were abnormal in 14% but resulted in significant change in management in only 4.5%.

Acute Respiratory Illness in Immunocompetent Patients. Findley and Sahn [37] recommended chest radiographs only when PNA or pneumothorax is suspected. White et al [39] found significant chest radiograph abnormalities in 34% of adults whose asthma exacerbation warranted hospital admission. CT Chest Although our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of patients with a high pretest probability of PNA presenting with an acute asthma exacerbation, patients who cannot reliably follow-up or for whom any delay in diagnosis of PNA could be life-threatening may warrant a CT if the chest radiograph is negative or equivocal. Chest radiographs are usually sufficient to diagnose pneumothorax. CT should be reserved for patients who require additional evaluation of their pneumothorax to look for an underlying cause. US Chest US may be a reasonable alternative to chest radiographs to identify PNA [8-12] and pneumothorax [13]. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with an acute asthma exacerbation. Acute Respiratory Illness in Immunocompetent Patients Variant 7: Acute COPD exacerbation in immunocompetent patients, uncomplicated (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Initial imaging. Radiography Chest The ATS defines a chronic obstructive pulmonary disease (COPD) flare as an acute worsening of COPD symptoms. Sherman et al [40] studied the usefulness of chest radiographs in 242 patients with acute exacerbations of COPD. Of this group, 135 patients (56%) had asthma, and 107 (44%) had emphysema and chronic bronchitis. Chest radiographs were abnormal in 14% but resulted in significant change in management in only 4.5%.

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acrac_69446_12

Acute Respiratory Illness in Immunocompetent Patients

CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. Variant 8: Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging. Radiography Chest Chest radiographs seem warranted in COPD patients with significant comorbidities or a higher pretest probability of PNA (such as those who are elderly or who have abnormal vital signs or physical examination findings). Sherman et al [40] suggested that a chest radiograph is indicated if a COPD exacerbation is accompanied by leukocytosis, chest pain, or edema, or by a history of coronary artery disease or congestive heart failure. US Chest Studies by Reissig et al [11] and Nazerian et al [10] included patients with COPD. There was no mention of how the presence of COPD might affect the ability of US to diagnose PNA. The presence of COPD did not appear to be a contraindication to US. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with a COPD exacerbation.

Acute Respiratory Illness in Immunocompetent Patients. CT Chest Our literature search failed to identify any data that suggest that CT serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. US Chest Our literature search failed to identify any data that suggest that US serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a low pretest probability of PNA presenting with a COPD exacerbation. Variant 8: Acute COPD exacerbation in immunocompetent patients with accompanying chest pain, fever, or leukocytosis, or a history of coronary artery disease, or heart failure. Initial imaging. Radiography Chest Chest radiographs seem warranted in COPD patients with significant comorbidities or a higher pretest probability of PNA (such as those who are elderly or who have abnormal vital signs or physical examination findings). Sherman et al [40] suggested that a chest radiograph is indicated if a COPD exacerbation is accompanied by leukocytosis, chest pain, or edema, or by a history of coronary artery disease or congestive heart failure. US Chest Studies by Reissig et al [11] and Nazerian et al [10] included patients with COPD. There was no mention of how the presence of COPD might affect the ability of US to diagnose PNA. The presence of COPD did not appear to be a contraindication to US. MRI Chest Our literature search failed to identify any data that suggest that MRI serves any significant role in the initial imaging of immunocompetent patients with a high pretest probability of PNA presenting with a COPD exacerbation.

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acrac_69446_13

Acute Respiratory Illness in Immunocompetent Patients

Summary of Recommendations Variant 1: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and a negative physical examination, normal vital signs, and no other risk factors. Variant 2: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Variant 3: Chest CT without IV contrast is usually appropriate for imaging immunocompetent patients with ARI and positive physical examination, abnormal vital signs, organic brain disease or other risk factors and a negative or equivocal initial chest radiograph. 10 Variant 4: Chest CT, with or without IV contrast, is usually appropriate for imaging immunocompetent patients with PNA complicated by suspected parapneumonic effusion or abscess on initial chest radiograph and MRI may be appropriate in this scenario. Variant 5: Imaging is usually not appropriate for the initial workup of immunocompetent patients presenting with an uncomplicated acute asthma exacerbation (no suspicion of PNA or pneumothorax) but a chest radiograph may be appropriate. Variant 6: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with a complicated acute asthma exacerbation (suspected PNA or pneumothorax). Variant 7: A chest radiograph is usually appropriate for the initial imaging of an uncomplicated acute COPD exacerbation in immunocompetent patients (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Variant 8: A chest radiograph is usually appropriate for the initial imaging of complicated acute COPD exacerbation in immunocompetent patients (chest pain, fever, leukocytosis, or a history of coronary artery disease, or heart failure).

Acute Respiratory Illness in Immunocompetent Patients. Summary of Recommendations Variant 1: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and a negative physical examination, normal vital signs, and no other risk factors. Variant 2: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with ARI and positive physical examination, abnormal vital signs, organic brain disease, or other risk factors. Variant 3: Chest CT without IV contrast is usually appropriate for imaging immunocompetent patients with ARI and positive physical examination, abnormal vital signs, organic brain disease or other risk factors and a negative or equivocal initial chest radiograph. 10 Variant 4: Chest CT, with or without IV contrast, is usually appropriate for imaging immunocompetent patients with PNA complicated by suspected parapneumonic effusion or abscess on initial chest radiograph and MRI may be appropriate in this scenario. Variant 5: Imaging is usually not appropriate for the initial workup of immunocompetent patients presenting with an uncomplicated acute asthma exacerbation (no suspicion of PNA or pneumothorax) but a chest radiograph may be appropriate. Variant 6: A chest radiograph is usually appropriate for the initial imaging of immunocompetent patients presenting with a complicated acute asthma exacerbation (suspected PNA or pneumothorax). Variant 7: A chest radiograph is usually appropriate for the initial imaging of an uncomplicated acute COPD exacerbation in immunocompetent patients (no chest pain, fever, or leukocytosis, no history of coronary artery disease, or heart failure). Variant 8: A chest radiograph is usually appropriate for the initial imaging of complicated acute COPD exacerbation in immunocompetent patients (chest pain, fever, leukocytosis, or a history of coronary artery disease, or heart failure).

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acrac_69436_0

Acute Trauma to the Ankle

Introduction/Background Ankle injuries are the most common injury presenting to primary care and emergency rooms [1,2], accounting for 4.4% of United States emergency room visits [3]. Acute ankle sprains (pain, swelling, limited mobility) make up the majority of these injuries, with an estimated incidence of 2 million per year [4]. Diagnosis of presence and degree of sprain, fracture, subluxation, dislocation, cartilage abnormalities, foreign bodies, or neurovascular involvement are critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5] and to avoid chronic pain and immobility. Appropriate use of ankle imaging guidelines and clinical decision support mechanisms is paramount [6,7]. The current standard clinical imaging guidelines to determine if radiographs are necessary are the Ottawa Ankle Rules (OAR), instituted in 1992. The OAR have been validated for adults and children >5 years of age [8] and recommend ankle radiographs in patients with the following clinical criteria in the acute setting: 1) inability to bear weight, 2) point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, or 3) inability to ambulate for 4 steps. For the purposes of this paper, the OAR will still apply during the first 1- to 3-week interval following initial injury. Multiple validation studies have confirmed OAR effectiveness and utility in obtaining appropriate imaging, reducing unnecessary radiographs and costs, and improving clinical outcomes [8-13]. Exclusionary Criteria OAR should not be used in children <5 years of age or in those patients with a neurologic abnormality affecting the lower leg with decreased sensation (eg, diabetic), altered sensorium, or inability to communicate [8,25,26]. Other 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.

Acute Trauma to the Ankle. Introduction/Background Ankle injuries are the most common injury presenting to primary care and emergency rooms [1,2], accounting for 4.4% of United States emergency room visits [3]. Acute ankle sprains (pain, swelling, limited mobility) make up the majority of these injuries, with an estimated incidence of 2 million per year [4]. Diagnosis of presence and degree of sprain, fracture, subluxation, dislocation, cartilage abnormalities, foreign bodies, or neurovascular involvement are critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5] and to avoid chronic pain and immobility. Appropriate use of ankle imaging guidelines and clinical decision support mechanisms is paramount [6,7]. The current standard clinical imaging guidelines to determine if radiographs are necessary are the Ottawa Ankle Rules (OAR), instituted in 1992. The OAR have been validated for adults and children >5 years of age [8] and recommend ankle radiographs in patients with the following clinical criteria in the acute setting: 1) inability to bear weight, 2) point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, or 3) inability to ambulate for 4 steps. For the purposes of this paper, the OAR will still apply during the first 1- to 3-week interval following initial injury. Multiple validation studies have confirmed OAR effectiveness and utility in obtaining appropriate imaging, reducing unnecessary radiographs and costs, and improving clinical outcomes [8-13]. Exclusionary Criteria OAR should not be used in children <5 years of age or in those patients with a neurologic abnormality affecting the lower leg with decreased sensation (eg, diabetic), altered sensorium, or inability to communicate [8,25,26]. Other 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.

69436

acrac_69436_1

Acute Trauma to the Ankle

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: publications@acr.org Acute Trauma to the Ankle possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer. Special Imaging Considerations Avoidance of manipulation of the ankle prior to radiographs in the absence of neurovascular deficit or critical skin injury is recommended in order to avoid remanipulation or complication in this setting [27]. Advances in MRI technology have facilitated short dedicated extremity MRI protocols in some centers that may be used as an emergent adjunct to radiographs [28]. OR Discussion of Procedures by Variant Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle with positive OAR. talus, or calcaneus, OR CT Ankle Although CT may be used in polytrauma patients to determine the extent of injury in complex fractures, CT is not routinely used as the first imaging study of acute trauma to the ankle with positive OAR when exclusionary criteria do not apply.

Acute Trauma to the Ankle. 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: publications@acr.org Acute Trauma to the Ankle possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer. Special Imaging Considerations Avoidance of manipulation of the ankle prior to radiographs in the absence of neurovascular deficit or critical skin injury is recommended in order to avoid remanipulation or complication in this setting [27]. Advances in MRI technology have facilitated short dedicated extremity MRI protocols in some centers that may be used as an emergent adjunct to radiographs [28]. OR Discussion of Procedures by Variant Variant 1: Adult or child 5 years of age or older. Acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial imaging. Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle with positive OAR. talus, or calcaneus, OR CT Ankle Although CT may be used in polytrauma patients to determine the extent of injury in complex fractures, CT is not routinely used as the first imaging study of acute trauma to the ankle with positive OAR when exclusionary criteria do not apply.

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MRI Ankle Although MRI may be used for occult injuries or suspicion for ligamentous tears in inversion injuries [29], it is not the first imaging study for the evaluation of acute trauma to the ankle with positive OAR. Radiography Ankle Radiographs are indicated in patients who meet OAR criteria as the initial imaging study. Studies demonstrate between 92% and 99% sensitivity for detecting ankle fracture using these guidelines, with <2% of those who are negative for fracture using the OAR actually having a fracture [13-15,30]. The OAR are validated in children >5 years of age and should not be used in patients meeting the exclusionary criteria listed above [8]. Typical radiographic protocols should include 3 standard views: anteroposterior, lateral, and mortise views to include the base of the fifth metatarsal bone distal to the tuberosity [31]. Although foot and ankle radiographs have been performed together in clinical settings in the past, in a retrospective study of 243 patients with both radiographs performed, no foot fractures other than the base of the fifth metatarsal were noted. In the presence of inversion injury or fracture of the ankle, foot or knee radiographs should not be performed owing to low yield [32,33]. Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability, because the most important criterion in treatment of malleolar fractures is stability. A medial clear space of <4 mm should confirm stability. Increased incidence of fracture and instability is noted with medial tenderness, bruising or swelling, fibular fracture above the syndesmosis, bi- or trimalleolar fractures, open fracture, or high- energy fracture injury [34]. Special scenarios that warrant special mention and additional views include: Acute Trauma to the Ankle US Ankle Ultrasound (US) may be useful but is not typically considered the first line of imaging for the evaluation of acute trauma to the ankle with positive OAR [41].

Acute Trauma to the Ankle. MRI Ankle Although MRI may be used for occult injuries or suspicion for ligamentous tears in inversion injuries [29], it is not the first imaging study for the evaluation of acute trauma to the ankle with positive OAR. Radiography Ankle Radiographs are indicated in patients who meet OAR criteria as the initial imaging study. Studies demonstrate between 92% and 99% sensitivity for detecting ankle fracture using these guidelines, with <2% of those who are negative for fracture using the OAR actually having a fracture [13-15,30]. The OAR are validated in children >5 years of age and should not be used in patients meeting the exclusionary criteria listed above [8]. Typical radiographic protocols should include 3 standard views: anteroposterior, lateral, and mortise views to include the base of the fifth metatarsal bone distal to the tuberosity [31]. Although foot and ankle radiographs have been performed together in clinical settings in the past, in a retrospective study of 243 patients with both radiographs performed, no foot fractures other than the base of the fifth metatarsal were noted. In the presence of inversion injury or fracture of the ankle, foot or knee radiographs should not be performed owing to low yield [32,33]. Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability, because the most important criterion in treatment of malleolar fractures is stability. A medial clear space of <4 mm should confirm stability. Increased incidence of fracture and instability is noted with medial tenderness, bruising or swelling, fibular fracture above the syndesmosis, bi- or trimalleolar fractures, open fracture, or high- energy fracture injury [34]. Special scenarios that warrant special mention and additional views include: Acute Trauma to the Ankle US Ankle Ultrasound (US) may be useful but is not typically considered the first line of imaging for the evaluation of acute trauma to the ankle with positive OAR [41].

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Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging. Bone Scan Ankle Bone scan is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. CT Ankle CT is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. MRI Ankle MRI is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. Radiography Ankle Radiography is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. US Ankle US is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging. OAR should not be used in patients with neurologic abnormality involving the lower leg or those with decreased sensation (eg, diabetics), altered sensorium, or inability to communicate [25,26]. Other possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer. Acute Trauma to the Ankle Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.

Acute Trauma to the Ankle. Variant 2: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)). Patient meets the requirements for evaluation by the Ottawa Ankle Rules which are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Able to walk. Initial imaging. Bone Scan Ankle Bone scan is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. CT Ankle CT is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. MRI Ankle MRI is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. Radiography Ankle Radiography is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. US Ankle US is not routinely indicated as the first imaging study for evaluation of acute trauma to the ankle in this clinical scenario. Variant 3: Adult or child 5 years of age or older. Acute trauma to the ankle. Exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other). Patient does not meet requirements for evaluation by the Ottawa Ankle Rules. Initial imaging. OAR should not be used in patients with neurologic abnormality involving the lower leg or those with decreased sensation (eg, diabetics), altered sensorium, or inability to communicate [25,26]. Other possible cautionary or exclusionary scenarios include pregnancy, penetrating trauma, or presence of prior recent outside radiographs on transfer. Acute Trauma to the Ankle Bone Scan Ankle Bone scan is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.

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CT Ankle The imaging pathway is dependent on the severity of the trauma in patients within this particular clinical scenario. In the high-energy trauma patient or polytrauma patient, fractures and dislocations may be more difficult to identify clinically in the neurologically impaired or neuropathy patient. Occasionally, multidetector CT can be useful as first-line imaging study, particularly for complex injuries such as posterior malleolar fracture and posterior pilon variant fractures, which fall outside the typical classification systems. In a study of 270 patients by Switaj et al [41], the frequency of posterior malleolus fractures and posterior pilon variants was 50% and 20%, respectively; both were found more commonly in older females and diabetic patients. Recent studies of use and implementation of low-dose weight-bearing cone beam CT, particularly in the pediatric population, may be a viable alternative to standard CT studies [42]. MRI Ankle MRI is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or neurological disorder or other exclusionary criteria. Radiography Ankle In patients with diabetic neuropathy, neurologic compromise of the lower leg, or other exclusionary criteria in which application of the OAR is not possible and fracture is suspected, ankle radiographs are considered the initial imaging study. These patients may have no pain or point tenderness and may walk without discomfort despite fracture because of poor pain proprioception [25]. If there is high suspicion for foreign body, radiographs may also be useful for identification if the foreign body is radiopaque in nature. Radiography Ankle Stress Views Ankle stress views are not the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.

Acute Trauma to the Ankle. CT Ankle The imaging pathway is dependent on the severity of the trauma in patients within this particular clinical scenario. In the high-energy trauma patient or polytrauma patient, fractures and dislocations may be more difficult to identify clinically in the neurologically impaired or neuropathy patient. Occasionally, multidetector CT can be useful as first-line imaging study, particularly for complex injuries such as posterior malleolar fracture and posterior pilon variant fractures, which fall outside the typical classification systems. In a study of 270 patients by Switaj et al [41], the frequency of posterior malleolus fractures and posterior pilon variants was 50% and 20%, respectively; both were found more commonly in older females and diabetic patients. Recent studies of use and implementation of low-dose weight-bearing cone beam CT, particularly in the pediatric population, may be a viable alternative to standard CT studies [42]. MRI Ankle MRI is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or neurological disorder or other exclusionary criteria. Radiography Ankle In patients with diabetic neuropathy, neurologic compromise of the lower leg, or other exclusionary criteria in which application of the OAR is not possible and fracture is suspected, ankle radiographs are considered the initial imaging study. These patients may have no pain or point tenderness and may walk without discomfort despite fracture because of poor pain proprioception [25]. If there is high suspicion for foreign body, radiographs may also be useful for identification if the foreign body is radiopaque in nature. Radiography Ankle Stress Views Ankle stress views are not the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria.

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US Ankle US is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria. US may be useful as a secondary step in evaluation of foreign bodies or focal fluid collections. Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study. Acute trauma includes immediate time of injury to <3 weeks, whereas subacute trauma includes 3 weeks to <6 months. The timeframe of this clinical scenario is at the intersection of the late acute and subacute phases, and the OAR criteria can still apply for acute ankle trauma in this setting. Persistent pain may be associated with a radiographically occult fracture, bone contusion, subtle cartilage injury, soft-tissue injury, or foreign body not visible on radiographic examination. Diagnosis is critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5]. Bone Scan Ankle Bone scan is typically not used as the next step in this clinical scenario. CT Ankle CT of the ankle without intravenous (IV) contrast is useful in the trauma setting as the next study to evaluate for radiographically occult fractures and soft-tissue abnormalities. It is rare (<1%) for patients with a large joint effusion but no discernible fracture on radiographic examination, however, CT proved useful in demonstrating a fracture in one-third of cases in one large study [43,44]. Talar fractures (lateral process or comminuted talar body/dome fractures) and fractures associated with the subtalar joint can be difficult to detect on radiographs but are well identified on CT [45,46]. In patients with spiral fractures of the tibia, there is a higher incidence of nondisplaced posterior malleolar fractures that may be missed on radiographic examination [47].

Acute Trauma to the Ankle. US Ankle US is not routinely used as the first imaging study for the evaluation of acute trauma to the ankle in the setting of peripheral neuropathy or other exclusionary criteria. US may be useful as a secondary step in evaluation of foreign bodies or focal fluid collections. Variant 4: Adult or child 5 years of age or older. Acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks. No exclusionary criteria present. Initial radiographs negative. Next study. Acute trauma includes immediate time of injury to <3 weeks, whereas subacute trauma includes 3 weeks to <6 months. The timeframe of this clinical scenario is at the intersection of the late acute and subacute phases, and the OAR criteria can still apply for acute ankle trauma in this setting. Persistent pain may be associated with a radiographically occult fracture, bone contusion, subtle cartilage injury, soft-tissue injury, or foreign body not visible on radiographic examination. Diagnosis is critical in determining appropriate and timely orthopedic fixation/treatment planning [1,5]. Bone Scan Ankle Bone scan is typically not used as the next step in this clinical scenario. CT Ankle CT of the ankle without intravenous (IV) contrast is useful in the trauma setting as the next study to evaluate for radiographically occult fractures and soft-tissue abnormalities. It is rare (<1%) for patients with a large joint effusion but no discernible fracture on radiographic examination, however, CT proved useful in demonstrating a fracture in one-third of cases in one large study [43,44]. Talar fractures (lateral process or comminuted talar body/dome fractures) and fractures associated with the subtalar joint can be difficult to detect on radiographs but are well identified on CT [45,46]. In patients with spiral fractures of the tibia, there is a higher incidence of nondisplaced posterior malleolar fractures that may be missed on radiographic examination [47].

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Acute Trauma to the Ankle

A comparison of multidetector CT versus radiography for ankle fracture detection demonstrated only 87% and 78% sensitivity, respectively, for calcaneal fracture and talar fractures by radiography as compared with CT [48]. Occult osteochondral fractures of the subtalar joint may only be visualized on CT, particularly in patients without Acute Trauma to the Ankle dislocation, with fractures involving the posterior facet, with associated massive swelling, or with failure to regain subtalar motion after a period of immobilization [49]. CT with IV contrast is not indicated in this scenario because soft-tissue abnormalities and fluid collections can be identified on noncontrast high-resolution CT studies. MRI Ankle MRI of the ankle without IV contrast is most sensitive for evaluation of occult fractures with associated bone marrow edema patterns, particularly in inversion injuries and persistent lateral ankle pain, as well as presence and extent of soft-tissue injuries [29]. Stress injuries of bone, including those of the weekend warrior, are best depicted by MRI [50]. MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. High-resolution evaluation of the tendons and ligaments allows distinction between tendinopathy, sprain, and partial or complete tears. Ligament and tendon injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography.

Acute Trauma to the Ankle. A comparison of multidetector CT versus radiography for ankle fracture detection demonstrated only 87% and 78% sensitivity, respectively, for calcaneal fracture and talar fractures by radiography as compared with CT [48]. Occult osteochondral fractures of the subtalar joint may only be visualized on CT, particularly in patients without Acute Trauma to the Ankle dislocation, with fractures involving the posterior facet, with associated massive swelling, or with failure to regain subtalar motion after a period of immobilization [49]. CT with IV contrast is not indicated in this scenario because soft-tissue abnormalities and fluid collections can be identified on noncontrast high-resolution CT studies. MRI Ankle MRI of the ankle without IV contrast is most sensitive for evaluation of occult fractures with associated bone marrow edema patterns, particularly in inversion injuries and persistent lateral ankle pain, as well as presence and extent of soft-tissue injuries [29]. Stress injuries of bone, including those of the weekend warrior, are best depicted by MRI [50]. MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. High-resolution evaluation of the tendons and ligaments allows distinction between tendinopathy, sprain, and partial or complete tears. Ligament and tendon injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography.

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Presence of bone bruise and adjacent soft-tissue edema have shown a higher association with acute ligamentous injuries (anterior talofibular ligament most common) and tendon abnormalities [53,54] in patients with negative radiographs. MRI can also help exclude Salter 1 fractures in the pediatric population [55]. Radiography Ankle Repeat radiographs are not typically the next study but may be of use to identify early callous formation at an occult fracture line or possible mineralization at a site of intramuscular hematoma if contusion occurred during trauma. Radiographs with better technique may assist in diagnosis of subtle injuries such as the lateral talar process avulsion, which may erroneously be diagnosed as a lateral ankle sprain [37]. Radiography Ankle Stress Views Although ankle stress views are not the typical next best study for this patient group, if there is clinical evidence of instability on physician maneuvers, ankle stress views may be of benefit for identification of occult avulsion injury at ligamentous attachments that may contribute to widening of the joint space on radiographic stress views. US Ankle US is not typically the next imaging study. US may be useful as a secondary evaluation modality for focused evaluation of underlying soft-tissue injuries and ligaments, with the added benefit of dynamic imaging. This includes focused high-resolution US of the peroneal tendons and the superior peroneal retinaculum [56], stress US (during anterior drawer) to assess joint laxity or chondral avulsion fractures associated with lateral ligament injury in children with negative radiographs [57,58], and potential detection of superficial occult fractures at the base of the fifth metatarsal, lateral malleolus, and malleolus [41]. Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.

Acute Trauma to the Ankle. Presence of bone bruise and adjacent soft-tissue edema have shown a higher association with acute ligamentous injuries (anterior talofibular ligament most common) and tendon abnormalities [53,54] in patients with negative radiographs. MRI can also help exclude Salter 1 fractures in the pediatric population [55]. Radiography Ankle Repeat radiographs are not typically the next study but may be of use to identify early callous formation at an occult fracture line or possible mineralization at a site of intramuscular hematoma if contusion occurred during trauma. Radiographs with better technique may assist in diagnosis of subtle injuries such as the lateral talar process avulsion, which may erroneously be diagnosed as a lateral ankle sprain [37]. Radiography Ankle Stress Views Although ankle stress views are not the typical next best study for this patient group, if there is clinical evidence of instability on physician maneuvers, ankle stress views may be of benefit for identification of occult avulsion injury at ligamentous attachments that may contribute to widening of the joint space on radiographic stress views. US Ankle US is not typically the next imaging study. US may be useful as a secondary evaluation modality for focused evaluation of underlying soft-tissue injuries and ligaments, with the added benefit of dynamic imaging. This includes focused high-resolution US of the peroneal tendons and the superior peroneal retinaculum [56], stress US (during anterior drawer) to assess joint laxity or chondral avulsion fractures associated with lateral ligament injury in children with negative radiographs [57,58], and potential detection of superficial occult fractures at the base of the fifth metatarsal, lateral malleolus, and malleolus [41]. Variant 5: Adult or child 5 years of age or older. Acute trauma to the ankle. No exclusionary criteria present. Radiographs demonstrate fracture or potential osteochondral injury. Next study.

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Bone Scan Ankle Osteochondral lesions Bone scan is not the next imaging study in this clinical scenario. Fractures Bone scan is not the next imaging study in this clinical scenario. Bone scan may be used in rare setting in polytrauma cases for evaluation of multiple fractures. CT Ankle Osteochondral lesions Although MRI is the reference standard, CT is also of utility to identify, locate, and quantify cortical and subcortical involvement or loss as well as presence of intra-articular ossific bodies or associated fractures. In a prospective study of 399 patients, uncontained osteochondral lesion of the talus shoulder, as determined arthroscopically, had a more complicated clinical outcome than those with nonshoulder lesions, confirming the importance of imaging localization for clinical outcome [59]. An inverted osteochondral fracture of the lateral talus (lateral, inverted, Acute Trauma to the Ankle fracture talus, also known as the LIFT lesion) can occur after twisting injury to the ankle. Initial radiographs should be followed by CT and MRI [60,61]. These lesions are treated successfully with combined open approach and arthroscopy. Fractures CT is the first-line imaging study after radiographs to determine extent, displacement, comminution, intra-articular extension, associated injuries, and potential classification of fractures [48]. This is particularly important in subtalar, calcaneal, and talar fractures because of the complex anatomy and in high-impact polytrauma or complex comminuted injuries in which multiplanar CT imaging is recommended to help direct the preoperative planning evaluation process [62]. MRI Ankle Osteochondral lesions MRI without IV contrast is considered the study of choice for assessment of cartilage abnormalities and bone contusions related to acquired osteochondral lesion, particularly in patients with symptoms of persistent pain, stiffness, locking, clicking, and ankle swelling [22,55-57,63].

Acute Trauma to the Ankle. Bone Scan Ankle Osteochondral lesions Bone scan is not the next imaging study in this clinical scenario. Fractures Bone scan is not the next imaging study in this clinical scenario. Bone scan may be used in rare setting in polytrauma cases for evaluation of multiple fractures. CT Ankle Osteochondral lesions Although MRI is the reference standard, CT is also of utility to identify, locate, and quantify cortical and subcortical involvement or loss as well as presence of intra-articular ossific bodies or associated fractures. In a prospective study of 399 patients, uncontained osteochondral lesion of the talus shoulder, as determined arthroscopically, had a more complicated clinical outcome than those with nonshoulder lesions, confirming the importance of imaging localization for clinical outcome [59]. An inverted osteochondral fracture of the lateral talus (lateral, inverted, Acute Trauma to the Ankle fracture talus, also known as the LIFT lesion) can occur after twisting injury to the ankle. Initial radiographs should be followed by CT and MRI [60,61]. These lesions are treated successfully with combined open approach and arthroscopy. Fractures CT is the first-line imaging study after radiographs to determine extent, displacement, comminution, intra-articular extension, associated injuries, and potential classification of fractures [48]. This is particularly important in subtalar, calcaneal, and talar fractures because of the complex anatomy and in high-impact polytrauma or complex comminuted injuries in which multiplanar CT imaging is recommended to help direct the preoperative planning evaluation process [62]. MRI Ankle Osteochondral lesions MRI without IV contrast is considered the study of choice for assessment of cartilage abnormalities and bone contusions related to acquired osteochondral lesion, particularly in patients with symptoms of persistent pain, stiffness, locking, clicking, and ankle swelling [22,55-57,63].

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Although radiographs and CT depict ossific fragments and fracture lines, cartilage abnormalities and bone contusions related to osteochondral lesion are best seen on MRI. Seventy percent of ankle fractures and 50% of ankle sprains have been shown to result in some variation of cartilage injury [57,58,61,64]. Fractures Although CT is more commonly used as the next step in fracture assessment in known fractures, MRI can be useful as a follow-up imaging modality for assessment of associated bone marrow contusions, stress injuries, or fractures [65]. MRI is especially important in fracture sites such as the talus, which are at higher risk for osteonecrosis. MRI is highly accurate for associated soft-tissue abnormalities including tendon entrapment/dislocation and for ligamentous injuries [66]. US Ankle Osteochondral lesion US is not the next step in this clinical scenario. Fractures US has been shown to be useful for identification of lateral malleolar, medial malleolar, and fifth metatarsal fractures [41] but is not considered a first-line assessment tool or next imaging study in this clinical scenario. Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study. Lateral sprain is more common than medial strain, with the anterior talofibular ligament most commonly torn. High sprain and fractures are more common in high-collision sport injuries [60], with higher incidence of ankle injuries during winter months [67] and increased incidence in military recruits [68]. Inversion injuries of the ankle account for 25% of musculoskeletal system injuries and 50% of all sports-related injuries [1]. Bone Scan Ankle Bone scan is not routinely the next line of imaging in this clinical scenario. Acute Trauma to the Ankle

Acute Trauma to the Ankle. Although radiographs and CT depict ossific fragments and fracture lines, cartilage abnormalities and bone contusions related to osteochondral lesion are best seen on MRI. Seventy percent of ankle fractures and 50% of ankle sprains have been shown to result in some variation of cartilage injury [57,58,61,64]. Fractures Although CT is more commonly used as the next step in fracture assessment in known fractures, MRI can be useful as a follow-up imaging modality for assessment of associated bone marrow contusions, stress injuries, or fractures [65]. MRI is especially important in fracture sites such as the talus, which are at higher risk for osteonecrosis. MRI is highly accurate for associated soft-tissue abnormalities including tendon entrapment/dislocation and for ligamentous injuries [66]. US Ankle Osteochondral lesion US is not the next step in this clinical scenario. Fractures US has been shown to be useful for identification of lateral malleolar, medial malleolar, and fifth metatarsal fractures [41] but is not considered a first-line assessment tool or next imaging study in this clinical scenario. Variant 6: Adult or child 5 years of age or older. Acute trauma to the ankle. Radiographs negative for osseous injury and physical examination or radiographs demonstrate alignment abnormality suggesting syndesmotic/ligamentous injury or dislocation. Next study. Lateral sprain is more common than medial strain, with the anterior talofibular ligament most commonly torn. High sprain and fractures are more common in high-collision sport injuries [60], with higher incidence of ankle injuries during winter months [67] and increased incidence in military recruits [68]. Inversion injuries of the ankle account for 25% of musculoskeletal system injuries and 50% of all sports-related injuries [1]. Bone Scan Ankle Bone scan is not routinely the next line of imaging in this clinical scenario. Acute Trauma to the Ankle

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Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71]. MRI Ankle MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. Ligamentous injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography. Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71]. Radiography Ankle Stress Views Stress radiographs may be useful in assessing syndesmotic instability, particularly in supination external rotation ankle injuries according to the Lauge-Hansen classification. Lee et al [72] noted that tibiotalar tilt angle and anterior tibiofibular space measurements were affected when the anterior tibiofibular and posterior talofibular ligaments were injured (confirmed on MRI) in 299 patients. Lateral stress testing with widening of the tibiofibular clear space has been shown to be an indicator of syndesmotic injury, with the traditional external rotation stress test shown to be a poor indicator when the deltoid ligament is injured [73]. Radiography Leg Maisonneuve fracture (syndesmotic injury of the ankle in combination with a proximal fibular fracture) may be overlooked as a result of lack of pain at the fibula. Careful palpation of the proximal fibula should be performed with radiographic evaluation of the entire tibia and fibular if focal tenderness is present [74].

Acute Trauma to the Ankle. Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71]. MRI Ankle MRI is the reference standard for ligamentous injury and assessment of stability, which is particularly important in athletes, in whom determination of grade (1, 2, or 3) of syndesmotic ligament, anterior tibiofibular ligament, and deltoid injuries is critical for treatment planning and return to sport assessment [51]. Ligamentous injuries can occur without fracture on radiography. Grossterlinden et al [52] compared MRI and radiography and showed that 15% of ligamentous injuries (including sprains, partial tears, and complete tears) at the syndesmosis in acute ankle injuries on MRI demonstrated no fracture on radiography. Rare pantalar dislocations without associated talar or other fracture can be assessed on CT or MRI and have high rates of osteonecrosis, osteoarthritis, and infection [71]. Radiography Ankle Stress Views Stress radiographs may be useful in assessing syndesmotic instability, particularly in supination external rotation ankle injuries according to the Lauge-Hansen classification. Lee et al [72] noted that tibiotalar tilt angle and anterior tibiofibular space measurements were affected when the anterior tibiofibular and posterior talofibular ligaments were injured (confirmed on MRI) in 299 patients. Lateral stress testing with widening of the tibiofibular clear space has been shown to be an indicator of syndesmotic injury, with the traditional external rotation stress test shown to be a poor indicator when the deltoid ligament is injured [73]. Radiography Leg Maisonneuve fracture (syndesmotic injury of the ankle in combination with a proximal fibular fracture) may be overlooked as a result of lack of pain at the fibula. Careful palpation of the proximal fibula should be performed with radiographic evaluation of the entire tibia and fibular if focal tenderness is present [74].

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acrac_69436_11

Acute Trauma to the Ankle

US Ankle US is not typically the next line of evaluation of syndesmotic injuries. Although some studies have suggested focused US could be beneficial for ligamentous evaluation, others have shown limited utility in lateral ankle ligament sprains [75]. Summary of Recommendations Variant 1: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks with no exclusionary criteria present and the OAR are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Variant 2: Imaging is usually not appropriate for patients 5 years of age or older with acute trauma to the ankle when the patient is able to walk and there are no exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)) and the OAR are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Variant 3: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle when exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other) and the patient does not meet requirements for evaluation by the OAR. Acute Trauma to the Ankle ankle without IV contrast is more likely to be performed for known fracture evaluation with MRI ankle without IV contrast more likely to be performed for potential osteochondral injury evaluation. 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 Ankle. US Ankle US is not typically the next line of evaluation of syndesmotic injuries. Although some studies have suggested focused US could be beneficial for ligamentous evaluation, others have shown limited utility in lateral ankle ligament sprains [75]. Summary of Recommendations Variant 1: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle or acute trauma to the ankle with persistent pain for more than 1 week but less than 3 weeks with no exclusionary criteria present and the OAR are positive: 1. Inability to bear weight immediately after the injury, OR 2. Point tenderness over the medial malleolus, the posterior edge or inferior tip of the lateral malleolus, talus, or calcaneus, OR 3. Inability to ambulate for 4 steps in the emergency department. Variant 2: Imaging is usually not appropriate for patients 5 years of age or older with acute trauma to the ankle when the patient is able to walk and there are no exclusionary criteria present (eg, neurologically intact (including no peripheral neuropathy)) and the OAR are negative: No point tenderness over the malleoli, talus, or calcaneus on physical examination. Variant 3: Ankle radiographs are usually appropriate for the initial imaging of patients 5 years of age or older with acute trauma to the ankle when exclusionary criteria are present (eg, neurologic disorder, neuropathy, or other) and the patient does not meet requirements for evaluation by the OAR. Acute Trauma to the Ankle ankle without IV contrast is more likely to be performed for known fracture evaluation with MRI ankle without IV contrast more likely to be performed for potential osteochondral injury evaluation. 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.

69436

acrac_69507_0

Lower Extremity Chronic Venous Disease

Introduction/Background Lower extremity venous insufficiency is a common chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis (DVT) or extrinsic venous obstruction. Venous insufficiency may cause varicosities that vary in presentation from cosmetic concern to chronic lower extremity discomfort, swelling, induration, dermatitis, and ulceration [1]. Varicose veins are dilated and usually tortuous subcutaneous veins measuring at least 3 mm in diameter in an upright position, larger than reticular veins (subdermal veins, 1-3 mm in diameter) and telangiectasia (intradermal veins, <1 mm in diameter) [1]. Venous disease of the legs can be categorized according to the severity, cause, site, and specific abnormality using the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification system [1,2]. The elements of the CEAP classification include, 1) Clinical severity (grade 0-6, asymptomatic, symptomatic), 2) Etiology (congenital, primary, secondary), 3) Anatomical distribution (superficial, deep, perforator veins), and 4) Pathophysiological dysfunction (reflux, obstruction). Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million men and 22 million women 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease [3]. Approximate total prevalence of C2 to C3 disease is 25% and 5% for stages C4 to C6 [1,3]. Additionally, most chronic leg ulcers are venous in origin, with prevalence of nearly 1% [4,5]. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly [4]. Treatment of superficial venous insufficiency is intended to alleviate symptoms and reduce the risk of complications.

Lower Extremity Chronic Venous Disease. Introduction/Background Lower extremity venous insufficiency is a common chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis (DVT) or extrinsic venous obstruction. Venous insufficiency may cause varicosities that vary in presentation from cosmetic concern to chronic lower extremity discomfort, swelling, induration, dermatitis, and ulceration [1]. Varicose veins are dilated and usually tortuous subcutaneous veins measuring at least 3 mm in diameter in an upright position, larger than reticular veins (subdermal veins, 1-3 mm in diameter) and telangiectasia (intradermal veins, <1 mm in diameter) [1]. Venous disease of the legs can be categorized according to the severity, cause, site, and specific abnormality using the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification system [1,2]. The elements of the CEAP classification include, 1) Clinical severity (grade 0-6, asymptomatic, symptomatic), 2) Etiology (congenital, primary, secondary), 3) Anatomical distribution (superficial, deep, perforator veins), and 4) Pathophysiological dysfunction (reflux, obstruction). Lower extremity chronic venous disease has a high prevalence with a related socioeconomic burden. In the United States, over 11 million men and 22 million women 40 to 80 years of age have varicose veins, with over 2 million adults having advanced chronic venous disease [3]. Approximate total prevalence of C2 to C3 disease is 25% and 5% for stages C4 to C6 [1,3]. Additionally, most chronic leg ulcers are venous in origin, with prevalence of nearly 1% [4,5]. The high cost to the health care system is related to the recurrent nature of venous ulcerative disease, with total treatment costs estimated >$2.5 billion per year in the United States, with at least 20,556 individuals with newly diagnosed venous ulcers yearly [4]. Treatment of superficial venous insufficiency is intended to alleviate symptoms and reduce the risk of complications.

69507

acrac_69507_1

Lower Extremity Chronic Venous Disease

Conventional management targeted at reducing reflux has been surgical removal of the great saphenous vein (GSV) from the level of the saphenofemoral junction to the level of the knee or ankle (along with saphenous vein branch ligation in the groin). Alternatives to saphenous vein stripping and ligation include vein ablation using laser energy, radiofrequency-generated thermal energy, or chemical sclerosing agents [6-8]. Discussion of Procedures by Variant Variant 1: Varicose veins. Initial diagnosis. Catheter Venography Iliac Veins Catheter venography of the iliac veins can aid in evaluating proximal occlusions or significant stenosis when proximal varicosities are present. Adjunctive usage of intravascular ultrasound (IVUS) can improve the specificity aModern Vascular of Denver, Thornton, Colorado. bResearch Author, University of Colorado Denver, Denver, Colorado. cPanel Chair, University of Michigan, Ann Arbor, Michigan. dPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. ePanel Vice-Chair, University of California San Francisco, San Francisco, California. fPanel Vice-Chair, University of Vermont Medical Center, Burlington, Vermont. gDetroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan. hZucker School of Medicine at Hofstra Northwell, Hempstead, New York. iTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. jOregon Health and Science University, Portland, Oregon. kMedical University of South Carolina, Charleston, South Carolina. lRenaissance School of Medicine at Stony Brook University, Stony Brook, New York. mBoston University School of Medicine, Boston, Massachusetts. nMayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging. oWeill Cornell Medicine- New York Presbyterian Hospital, New York, New York; American Vein & Lymphatic Society. pFroedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin.

Lower Extremity Chronic Venous Disease. Conventional management targeted at reducing reflux has been surgical removal of the great saphenous vein (GSV) from the level of the saphenofemoral junction to the level of the knee or ankle (along with saphenous vein branch ligation in the groin). Alternatives to saphenous vein stripping and ligation include vein ablation using laser energy, radiofrequency-generated thermal energy, or chemical sclerosing agents [6-8]. Discussion of Procedures by Variant Variant 1: Varicose veins. Initial diagnosis. Catheter Venography Iliac Veins Catheter venography of the iliac veins can aid in evaluating proximal occlusions or significant stenosis when proximal varicosities are present. Adjunctive usage of intravascular ultrasound (IVUS) can improve the specificity aModern Vascular of Denver, Thornton, Colorado. bResearch Author, University of Colorado Denver, Denver, Colorado. cPanel Chair, University of Michigan, Ann Arbor, Michigan. dPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. ePanel Vice-Chair, University of California San Francisco, San Francisco, California. fPanel Vice-Chair, University of Vermont Medical Center, Burlington, Vermont. gDetroit Medical Center, Tenet Healthcare and Envision Radiology Physician Services, Detroit, Michigan. hZucker School of Medicine at Hofstra Northwell, Hempstead, New York. iTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. jOregon Health and Science University, Portland, Oregon. kMedical University of South Carolina, Charleston, South Carolina. lRenaissance School of Medicine at Stony Brook University, Stony Brook, New York. mBoston University School of Medicine, Boston, Massachusetts. nMayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging. oWeill Cornell Medicine- New York Presbyterian Hospital, New York, New York; American Vein & Lymphatic Society. pFroedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin.

69507

acrac_69507_2

Lower Extremity Chronic Venous Disease

qSpecialty Chair, Emory University Hospital, Atlanta, Georgia. rSpecialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin. 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: publications@acr.org Lower Extremity Chronic Venous Disease of such lesions. However, there is no relevant literature regarding the use of catheter-directed venography of the iliac veins when evaluating for varicose veins. Catheter Venography Lower Extremity Catheter venography is ideal in performing descending venography of the lower extremity to evaluate for deep vein reflux [9]. However, there is no relevant literature regarding the use of catheter-directed lower extremity venography in the evaluation of bilateral GSV insufficiency with visible varicose veins. CTV Lower Extremity CT venography (CTV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment, plan interventions, reduce recurrence, and decrease complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Limitations of this study include retrospective nature and possible selection bias given that it was a single center and consecutively acquired data. US has been championed as a best initial test.

Lower Extremity Chronic Venous Disease. qSpecialty Chair, Emory University Hospital, Atlanta, Georgia. rSpecialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin. 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: publications@acr.org Lower Extremity Chronic Venous Disease of such lesions. However, there is no relevant literature regarding the use of catheter-directed venography of the iliac veins when evaluating for varicose veins. Catheter Venography Lower Extremity Catheter venography is ideal in performing descending venography of the lower extremity to evaluate for deep vein reflux [9]. However, there is no relevant literature regarding the use of catheter-directed lower extremity venography in the evaluation of bilateral GSV insufficiency with visible varicose veins. CTV Lower Extremity CT venography (CTV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment, plan interventions, reduce recurrence, and decrease complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Limitations of this study include retrospective nature and possible selection bias given that it was a single center and consecutively acquired data. US has been championed as a best initial test.

69507

acrac_69507_3

Lower Extremity Chronic Venous Disease

However, there are rare cases in which US imaging is limited, such as obesity. In these cases, where characterization of lower extremity veins is suboptimal, CTV can be used adjunctively [9]. CTV Pelvis There is no relevant literature regarding the use of CTV of the pelvis in the evaluation of bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates. US Intravascular Iliac Veins There is no relevant literature regarding the use of iliac vein IVUS in the evaluation of bilateral GSV insufficiency with visible varicose veins. MRV Lower Extremity MR venography (MRV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy may be useful and could result in selecting more effective treatment [10-13]. In rare cases in which US imaging is limited, characterization of lower extremity veins is suboptimal, or the goal is to avoid iodinated contrast, MRV can be used adjunctively [9]. MRV Pelvis There is no relevant literature regarding the use of MRV of the pelvis in the evaluation of asymptomatic bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US evaluation should include condition of the deep venous system, GSV, small saphenous vein (SSV), and accessory saphenous veins.

Lower Extremity Chronic Venous Disease. However, there are rare cases in which US imaging is limited, such as obesity. In these cases, where characterization of lower extremity veins is suboptimal, CTV can be used adjunctively [9]. CTV Pelvis There is no relevant literature regarding the use of CTV of the pelvis in the evaluation of bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates. US Intravascular Iliac Veins There is no relevant literature regarding the use of iliac vein IVUS in the evaluation of bilateral GSV insufficiency with visible varicose veins. MRV Lower Extremity MR venography (MRV) of the lower extremity has not been cited as a first-line examination. However, given the high rate of recurrence 2 years postintervention (15%-35%), it has been suggested that further anatomic characterization before therapy may be useful and could result in selecting more effective treatment [10-13]. In rare cases in which US imaging is limited, characterization of lower extremity veins is suboptimal, or the goal is to avoid iodinated contrast, MRV can be used adjunctively [9]. MRV Pelvis There is no relevant literature regarding the use of MRV of the pelvis in the evaluation of asymptomatic bilateral GSV insufficiency with visible varicose veins. However, a comprehensive understanding of the anatomy could aid in the appropriate selection of treatment, planning interventions, and decreasing complication rates. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US evaluation should include condition of the deep venous system, GSV, small saphenous vein (SSV), and accessory saphenous veins.

69507

acrac_69507_4

Lower Extremity Chronic Venous Disease

Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation. Evaluation of venous structures should be accomplished via both transverse and longitudinal planes. Respiratory variation and cardiac pulsations are normally present and indicate a patent pathway to the heart [1]. The association between reflux and clinical manifestations of chronic venous disease is well established. Reflux, defined as retrograde venous flow >500 ms is almost always the result of primary degenerative changes within the venous wall and valves or as sequela of acute DVT causing destruction of venous valves [15]. Duplex Doppler US recordings should thus document presence, absence, and location of reflux. At a base level, abnormal reflux times should be measured and reported [16]. Variant 2: Varicose veins. Treatment. Compression Therapy Compression therapy has been widely described as the best initial treatment for varicose veins [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,21]. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20].

Lower Extremity Chronic Venous Disease. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation. Evaluation of venous structures should be accomplished via both transverse and longitudinal planes. Respiratory variation and cardiac pulsations are normally present and indicate a patent pathway to the heart [1]. The association between reflux and clinical manifestations of chronic venous disease is well established. Reflux, defined as retrograde venous flow >500 ms is almost always the result of primary degenerative changes within the venous wall and valves or as sequela of acute DVT causing destruction of venous valves [15]. Duplex Doppler US recordings should thus document presence, absence, and location of reflux. At a base level, abnormal reflux times should be measured and reported [16]. Variant 2: Varicose veins. Treatment. Compression Therapy Compression therapy has been widely described as the best initial treatment for varicose veins [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,21]. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20].

69507

acrac_69507_5

Lower Extremity Chronic Venous Disease

Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18]. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with quality of life (QoL) improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20]. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 and 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for venous leg ulcers (VLU) healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Saphenous Vein Ablation Endovenous ablation has largely supplanted surgical ligation and stripping as the main invasive method to treat varicose veins with similar efficacy, improved early QoL, and reduced hospital recovery [7,22,23]. The 2 types of endovenous ablation are radiofrequency ablation (RFA) and endovenous laser ablation (EVLA).

Lower Extremity Chronic Venous Disease. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18]. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with quality of life (QoL) improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20]. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 and 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for venous leg ulcers (VLU) healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Saphenous Vein Ablation Endovenous ablation has largely supplanted surgical ligation and stripping as the main invasive method to treat varicose veins with similar efficacy, improved early QoL, and reduced hospital recovery [7,22,23]. The 2 types of endovenous ablation are radiofrequency ablation (RFA) and endovenous laser ablation (EVLA).

69507

acrac_69507_6

Lower Extremity Chronic Venous Disease

RFA is a minimally invasive procedure in which a catheter is inserted into a target vein lumen. Intense, local heat- based energy through the catheter then obliterates the vein lumen and destroys the wall. EVLA uses laser energy that is absorbed by the target tissue and converted to heat. Both treatments use tumescent anesthesia, a method by which diluted local anesthetic with or without epinephrine and/or sodium bicarbonate are injected around the target vessel. This adjuvant protects the surrounding tissue and collapses the vein wall extrinsically to further ensure the target tissue is ablated in its entirety [7]. By 3 months post-treatment, endothelium is absent and organized thrombus is formed. Occlusion rates for these types of endovenous ablation vary from 91% to 100% within 1-year post- treatment [7,22]. Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28]. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference. So far, little difference is seen when comparing the various endovenous treatments in terms of QoL, benefit, and durability [15]. Current data on RFA versus EVLA is rather limited, although there have been some recent Lower Extremity Chronic Venous Disease developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm.

Lower Extremity Chronic Venous Disease. RFA is a minimally invasive procedure in which a catheter is inserted into a target vein lumen. Intense, local heat- based energy through the catheter then obliterates the vein lumen and destroys the wall. EVLA uses laser energy that is absorbed by the target tissue and converted to heat. Both treatments use tumescent anesthesia, a method by which diluted local anesthetic with or without epinephrine and/or sodium bicarbonate are injected around the target vessel. This adjuvant protects the surrounding tissue and collapses the vein wall extrinsically to further ensure the target tissue is ablated in its entirety [7]. By 3 months post-treatment, endothelium is absent and organized thrombus is formed. Occlusion rates for these types of endovenous ablation vary from 91% to 100% within 1-year post- treatment [7,22]. Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28]. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference. So far, little difference is seen when comparing the various endovenous treatments in terms of QoL, benefit, and durability [15]. Current data on RFA versus EVLA is rather limited, although there have been some recent Lower Extremity Chronic Venous Disease developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm.

69507

acrac_69507_7

Lower Extremity Chronic Venous Disease

A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1 month and 1 year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Though limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication when compared to EVLA [31]. We can conclude that the aggregate of evidence supports that ablation of saphenous veins provides significant benefits compared with compression [15]. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vein wall and ultimately occludes it secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated. Doppler US of the GSV ablated with foam at 1-year post-treatment demonstrated occlusion rates vary from 72% to 89%, which is lower compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7]. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed.

Lower Extremity Chronic Venous Disease. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1 month and 1 year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Though limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication when compared to EVLA [31]. We can conclude that the aggregate of evidence supports that ablation of saphenous veins provides significant benefits compared with compression [15]. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vein wall and ultimately occludes it secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated. Doppler US of the GSV ablated with foam at 1-year post-treatment demonstrated occlusion rates vary from 72% to 89%, which is lower compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7]. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed.

69507

acrac_69507_8

Lower Extremity Chronic Venous Disease

Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35]. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38]. There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA. Microphlebectomy Microphlebectomy involves the surgical excision of pathologic vessels.

Lower Extremity Chronic Venous Disease. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35]. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38]. There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA. Microphlebectomy Microphlebectomy involves the surgical excision of pathologic vessels.

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Lower Extremity Chronic Venous Disease

This method is used in combination with sclerotherapy ablation for best results. The most common complication involves skin blistering from dressing abrasions and adhesive tape. Wound infections may occur. Less commonly, small sensory nerves can be injured leading to areas of anesthesia and less commonly hyperesthesia. A rare injury could result from common peroneal nerve injury. The common peroneal nerve is commonly located just medial to the biceps femoris tendon and near the fibular head. Injury to this nerve can cause sensory loss or foot drop. When planning microphlebectomy, care or avoidance of this region is recommended [2]. Lower Extremity Chronic Venous Disease Variant 3: Venous leg ulcer. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after CTV/MRV has characterized an occlusion or stenosis [9]. Venography has been criticized for low sensitivity for identifying critical lesions in the iliac vein [41]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Catheter Venography Lower Extremity Digital subtraction ascending venography has been described as the next step in diagnosis after CTV or MRV has characterized an occlusion or stenosis [9]. Catheter-directed venography of the lower extremity is used mainly as part of a procedure in which treatment is planned for post-thrombotic and nonthrombotic obstruction of the iliac veins and much less often for post-thrombotic femoral veins. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is helpful after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%).

Lower Extremity Chronic Venous Disease. This method is used in combination with sclerotherapy ablation for best results. The most common complication involves skin blistering from dressing abrasions and adhesive tape. Wound infections may occur. Less commonly, small sensory nerves can be injured leading to areas of anesthesia and less commonly hyperesthesia. A rare injury could result from common peroneal nerve injury. The common peroneal nerve is commonly located just medial to the biceps femoris tendon and near the fibular head. Injury to this nerve can cause sensory loss or foot drop. When planning microphlebectomy, care or avoidance of this region is recommended [2]. Lower Extremity Chronic Venous Disease Variant 3: Venous leg ulcer. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after CTV/MRV has characterized an occlusion or stenosis [9]. Venography has been criticized for low sensitivity for identifying critical lesions in the iliac vein [41]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Catheter Venography Lower Extremity Digital subtraction ascending venography has been described as the next step in diagnosis after CTV or MRV has characterized an occlusion or stenosis [9]. Catheter-directed venography of the lower extremity is used mainly as part of a procedure in which treatment is planned for post-thrombotic and nonthrombotic obstruction of the iliac veins and much less often for post-thrombotic femoral veins. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is helpful after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%).

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Lower Extremity Chronic Venous Disease

Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment and reduce recurrence and complication rates. CTV Abdomen and Pelvis CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or inferior vena cava (IVC) involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment, thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that, in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42]. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. IVUS has also shown utility at predicting when stenting for iliofemoral vein stenosis will result in symptomatic improvement. One study involving CEAP C4 to C6 study population has shown significant improvement symptomatology in stenting >50% iliofemoral vein stenosis (50% area reduction chosen by authors) [41]. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy [10] could aid in the selection of the appropriate treatment modality and reduce recurrence and complication rates.

Lower Extremity Chronic Venous Disease. Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding the anatomy could aid in the appropriate selection of treatment and reduce recurrence and complication rates. CTV Abdomen and Pelvis CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or inferior vena cava (IVC) involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment, thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that, in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42]. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. IVUS has also shown utility at predicting when stenting for iliofemoral vein stenosis will result in symptomatic improvement. One study involving CEAP C4 to C6 study population has shown significant improvement symptomatology in stenting >50% iliofemoral vein stenosis (50% area reduction chosen by authors) [41]. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy [10] could aid in the selection of the appropriate treatment modality and reduce recurrence and complication rates.

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Lower Extremity Chronic Venous Disease

In cases in which characterization of lower extremity veins is suboptimal, MRV can be used adjunctively [9]. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. Additionally, duplex US evaluation should include the condition of the deep venous system, GSV, SSV and its thigh extension (Giacomini Vein), and accessory saphenous veins. Presence and location of perforating veins near a VLU should also be included in any duplex US evaluation [1]. Lower Extremity Chronic Venous Disease If after treatment an ulcer recurs, repeat duplex US should assess for recanalization of treated GSV or reflux into the Giacomini vein, transmitting to the short saphenous vein [8]. Arterial vascular characterization may also prove useful because it has been noted that 16% of patients with VLU have concomitant arterial occlusive disease, which is frequently not recognized [19,43]. US Duplex Doppler IVC and Iliac Veins As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44].

Lower Extremity Chronic Venous Disease. In cases in which characterization of lower extremity veins is suboptimal, MRV can be used adjunctively [9]. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. Additionally, duplex US evaluation should include the condition of the deep venous system, GSV, SSV and its thigh extension (Giacomini Vein), and accessory saphenous veins. Presence and location of perforating veins near a VLU should also be included in any duplex US evaluation [1]. Lower Extremity Chronic Venous Disease If after treatment an ulcer recurs, repeat duplex US should assess for recanalization of treated GSV or reflux into the Giacomini vein, transmitting to the short saphenous vein [8]. Arterial vascular characterization may also prove useful because it has been noted that 16% of patients with VLU have concomitant arterial occlusive disease, which is frequently not recognized [19,43]. US Duplex Doppler IVC and Iliac Veins As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44].

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acrac_69507_12

Lower Extremity Chronic Venous Disease

This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities. Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and also monitor success of treatment on follow-up. Variant 4: Venous leg ulcer. Treatment. Compression Therapy Compression therapy has been widely described as a helpful initial treatment for VLU [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,47]. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20]. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). The alternative, graduated compression bandage, in which more force is generated at the distal ankle over the calf, demonstrated inferior ejection fraction in refluxing vessels and lower extrinsic pressures compared with their negative graduated compression bandage counterparts.

Lower Extremity Chronic Venous Disease. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities. Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and also monitor success of treatment on follow-up. Variant 4: Venous leg ulcer. Treatment. Compression Therapy Compression therapy has been widely described as a helpful initial treatment for VLU [18-20]. Compression therapy involves the use of a wide varying degree of devices to provide extrinsic compression on the lower extremity. As a group, they reduce venous stasis in various ways. Edema is contained by reduction of capillary filtration, fluid shift into noncompressed regions, and improved lymphatic drainage. Veins are directly affected by increasing venous blood flow velocity, reducing blood pooling, and improving venous pumping function. Lastly, microcirculation is influenced by transient increases in sheer stress, which in turn causes the release of anti- inflammatory, vasodilating, and antithrombotic mediators [19,47]. When using compression therapy, a minimum pressure of 20 to 30 mm Hg is recommended. Pressures of 30 to 40 mm Hg are advised for more severe disease [20]. Of note, improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage). The alternative, graduated compression bandage, in which more force is generated at the distal ankle over the calf, demonstrated inferior ejection fraction in refluxing vessels and lower extrinsic pressures compared with their negative graduated compression bandage counterparts.

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acrac_69507_13

Lower Extremity Chronic Venous Disease

Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18]. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with QoL improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20]. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Saphenous Vein Ablation Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28].

Lower Extremity Chronic Venous Disease. Improved pressures and ejection fractions were also observed when placing the compression bandage over the calf versus the distal leg [18]. Until recently, it had been widely accepted that treatment failure typically results from noncompliance [16,17]. However, 2 high-quality systematic reviews have concluded that the current published data are inadequate. The weakness in the data relates to the reliance on surrogate outcomes and subjective clinical improvement. Though present, few data demonstrate correlation with QoL improvement with routine use of compression alone [15]. Adherence should nonetheless be encouraged with proper fitting, education, and detailed instructions [19,20]. Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised, however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Saphenous Vein Ablation Multiple recent meta-analyses confirm that EVLA and RFA are at least as efficacious, if not slightly more so, than surgery [12,24-26]. When compared to surgery, EVLA had fewer rates of bleeding, hematoma, and wound infection [24]. EVLA and RFA were also noted to have reduced rates of paresthesia compared to surgery [27]. A meta- analysis pooling 52 studies of both RFA and EVLA demonstrated postprocedural thrombotic events infrequently; DVT occurred in 0.3% of cases, and pulmonary embolism occurred in 0.1% of cases [28].

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Lower Extremity Chronic Venous Disease

Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference. Lower Extremity Chronic Venous Disease Gohel et al [48] compared timing of EVLA, either immediately (within 2 weeks) or deferred (after 6 months or resolution of ulcer) and determined that early EVLA resulted in faster healing of venous ulcers and more ulcer-free time. Current data on RFA versus EVLA is rather limited, although there have been some recent developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1-month and 1-year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Although limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication compared to EVLA [31]. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In foam sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vessel wall and occludes the affecting vasculature secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated.

Lower Extremity Chronic Venous Disease. Rates of recurrence between surgery and EVLA had conflicting data, with Paravastu et al [25] noting improved recurrence rates with EVLA at 6 weeks and 1 year and Pan et al [24] noting no significant difference. Lower Extremity Chronic Venous Disease Gohel et al [48] compared timing of EVLA, either immediately (within 2 weeks) or deferred (after 6 months or resolution of ulcer) and determined that early EVLA resulted in faster healing of venous ulcers and more ulcer-free time. Current data on RFA versus EVLA is rather limited, although there have been some recent developments. Gale et al [29] randomized 48 patients into EVLA and 46 patients into RFA, with 11 RFA patients demonstrating recurrence compared with 2 cases of recurrence in the EVLA arm. A meta-analysis showed not only no statistically significant difference in long-term outcomes between conventional surgery and endovenous therapy but also no statistically significant difference in long-term outcomes between RFA and EVLA or conventional surgery [30]. An additional meta-analysis including 792 EVLA-treated and 785 RFA-treated patients demonstrated the same safety and efficacy between the 2 treatment cohorts. Outcomes included 3-day and 10-day pain scores, 1-month and 1-year QoL, occlusion, thrombophlebitis, hematoma, and recanalization. Although limited, data from this meta-analysis suggest RFA seems to have a lower overall risk of complication compared to EVLA [31]. Compression Sclerotherapy Compression sclerotherapy has been used effectively in the treatment of varicose veins, reticular veins, and telangiectasias [7,14]. In foam sclerotherapy, a liquid or foamed sclerosing drug is injected into the lumen of the varicose vein. This sclerosant is a chemical that damages the vessel wall and occludes the affecting vasculature secondary to fibrotic transformation of the vessel. Foamed sclerosant is used to increase the surface area by which the luminal wall can be treated.

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acrac_69507_15

Lower Extremity Chronic Venous Disease

At 1-year post-treatment, occlusion rates vary from 72% to 89%, which is lower when compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7]. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35]. Iliac Vein Stenting If venography has characterized a central occlusive vascular insult as a culprit for disease that involves the iliocaval segments, angioplasty with possible stenting should be performed. Cases with large ulcers that have decreased in size from prior superficial vein ablation usually require iliac vein stenting to complete ulcer healing [8]. Post-thrombotic iliac vein obstruction can lead to many QoL affecting symptoms including pain, swelling, and VLU. Multiple studies have shown iliac vein stenting to be advantageous with iliac vein stenosis >50%.

Lower Extremity Chronic Venous Disease. At 1-year post-treatment, occlusion rates vary from 72% to 89%, which is lower when compared to EVLA at 1 year [7,32]. Sclerosant can also be administered over a rotating wire, which causes local trauma to the vessel. This form of mechanochemical ablation has closure rates that vary from 88% to 94% in the literature [7]. Advantages of these chemical ablative techniques include a lack of potential thermal injury that could injure the skin, nerves, muscles, and nontarget blood vessels, which is rarely seen with endovenous ablation. Additionally, because of a lack of thermal energy, tumescent anesthesia is not needed. Potential complications include phlebitis, new telangiectasias, and residual pigmentations. Exceedingly rare complications include DVT [7]. Other nontumescent techniques that are used are cyanoacrylate glue. Risk factors would be allergies to adhesives. Multiple studies have shown that, compared with conventional open surgery and EVLA, chemical sclerotherapy has worse outcomes at 1-, 5-, and 8-year follow-ups, with higher rates of recurrent GSV reflux and saphenofemoral junction failure [33-36]. There are conflicting data on QoL, however, with equivalent improvement reported per the Aberdeen Varicose Vein Severity Score [36] and inferior improvement reported per the Chronic Venous Insufficiency Quality of Life Questionnaire [35]. Iliac Vein Stenting If venography has characterized a central occlusive vascular insult as a culprit for disease that involves the iliocaval segments, angioplasty with possible stenting should be performed. Cases with large ulcers that have decreased in size from prior superficial vein ablation usually require iliac vein stenting to complete ulcer healing [8]. Post-thrombotic iliac vein obstruction can lead to many QoL affecting symptoms including pain, swelling, and VLU. Multiple studies have shown iliac vein stenting to be advantageous with iliac vein stenosis >50%.

69507

acrac_69507_16

Lower Extremity Chronic Venous Disease

Rossi et al [49] attests that compared with medial therapy alone, QoL and symptomatology are dramatically improved in both the short and long term with iliac vein stenting and medial therapy. A meta-analysis of available studies demonstrated that iliac vein stenting improved pain, swelling, and venous ulcer healing with secondary patency rates acceptable given relatively low overall risk [15]. Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of venous ulcers. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38]. Lower Extremity Chronic Venous Disease There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA. Wound Care Although literature has shown benefit in ulcer debridement in improving venous ulcer, the optimal protocol for wound care is yet to be elucidated. Beyond debridement, wound exudate control and surface bacteria management are additional important goals in wound care.

Lower Extremity Chronic Venous Disease. Rossi et al [49] attests that compared with medial therapy alone, QoL and symptomatology are dramatically improved in both the short and long term with iliac vein stenting and medial therapy. A meta-analysis of available studies demonstrated that iliac vein stenting improved pain, swelling, and venous ulcer healing with secondary patency rates acceptable given relatively low overall risk [15]. Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of venous ulcers. Ligation and Stripping Higher rates of GSV reflux recurrence are identified with EVLA compared with high ligation and stripping. Both EVLA and high ligation and stripping, however, were noted to have similar metrics on disease specific QoL [37- 39]. Another study comparing high ligation and stripping versus EVLA in patients with GSV incompetence showed no significant difference between the 2 groups in recurrent GSV reflux, recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and QoL scores in a 5-year follow-up [40]. The RELACS study demonstrated, specifically, that high ligation and stripping was superior to EVLA in recurrence rates 5 years post- treatment [38]. Lower Extremity Chronic Venous Disease There are conflicting data regarding procedural complications. Pan et al [24] affirms that there is no significant difference in postprocedural phlebitis and bruising and concludes that there are fewer complications regarding bleeding, hematoma, wound infection, and paresthesia with EVLA. Rass et al [39], on the other hand, affirms that higher rates of phlebitis, tightness, and dyspigmentation were noted with EVLA. Wound Care Although literature has shown benefit in ulcer debridement in improving venous ulcer, the optimal protocol for wound care is yet to be elucidated. Beyond debridement, wound exudate control and surface bacteria management are additional important goals in wound care.

69507

acrac_69507_17

Lower Extremity Chronic Venous Disease

Antibiotic dressings, however, have shown no benefit. Adjuncts such as topical dressings to control wound exudate and maintain moisture as well as skin protectants are also important [6,21]. Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis. Catheter Venography Pelvis Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after US of the iliac veins, ovarian veins, renal veins, and IVC, CTV/MRV has characterized an occlusion or stenosis [9]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Pelvic varices can sometimes be demonstrated with direct catheterization plus or minus balloon occlusion. CTV Abdomen and Pelvis There is no relevant literature regarding the use of CTV abdomen and pelvis in the evaluation of pelvic-derived lower extremity varicose veins in women. This examination can be useful in evaluating the anatomy of dilated ovarian veins and nutcracker phenomenon, which can explain connections to pelvic-origin lower extremity varicose veins. CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or IVC involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42].

Lower Extremity Chronic Venous Disease. Antibiotic dressings, however, have shown no benefit. Adjuncts such as topical dressings to control wound exudate and maintain moisture as well as skin protectants are also important [6,21]. Variant 5: Suspected pelvic-origin lower extremity varicose veins in females. Initial diagnosis. Catheter Venography Pelvis Catheter-directed venography of the iliac veins has been described as the next step in diagnosis after US of the iliac veins, ovarian veins, renal veins, and IVC, CTV/MRV has characterized an occlusion or stenosis [9]. Venographic findings can be grouped into normal, stenosis, and occlusion [8]. Pelvic varices can sometimes be demonstrated with direct catheterization plus or minus balloon occlusion. CTV Abdomen and Pelvis There is no relevant literature regarding the use of CTV abdomen and pelvis in the evaluation of pelvic-derived lower extremity varicose veins in women. This examination can be useful in evaluating the anatomy of dilated ovarian veins and nutcracker phenomenon, which can explain connections to pelvic-origin lower extremity varicose veins. CTV of the abdomen and pelvis has been suggested in the literature in cases with signs of iliac or IVC involvement [9]. Further anatomic characterization before therapy can ensure appropriate and effective treatment thus reducing the frequency for reintervention [10-13]. Understanding the anatomy could aid in the selection of an appropriate treatment modality and reduce recurrence and complication rates. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific imaging modality for detecting deep vein obstructive disease. Compared to multiplanar venography, IVUS has been found to be more sensitive for detecting significant stenosis. One study found that in 26.3% of patients, significant lesions were detected with IVUS not initially seen with 3- view venography [42].

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acrac_69507_18

Lower Extremity Chronic Venous Disease

Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. US Intravascular Renal Veins There is no relevant literature regarding the use of IVUS for renal veins in the evaluation of pelvic-derived lower extremity varicose veins in women, although it can accurately characterize the severity of a stenosis of a renal vein but compression over the adjacent aorta and superior mesenteric artery. MRV Abdomen and Pelvis MRV of the abdomen and pelvis can identify stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. MRV can also demonstrate the diameters of pelvic veins and ovarian veins to identify those that are varicose (>5 mm periuterine and periovarian veins and >6- 8 mm in diameter ovarian veins) [50]. Further highlighting the importance of MRV before intervention is a high Lower Extremity Chronic Venous Disease rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1].

Lower Extremity Chronic Venous Disease. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. US Intravascular Renal Veins There is no relevant literature regarding the use of IVUS for renal veins in the evaluation of pelvic-derived lower extremity varicose veins in women, although it can accurately characterize the severity of a stenosis of a renal vein but compression over the adjacent aorta and superior mesenteric artery. MRV Abdomen and Pelvis MRV of the abdomen and pelvis can identify stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. MRV can also demonstrate the diameters of pelvic veins and ovarian veins to identify those that are varicose (>5 mm periuterine and periovarian veins and >6- 8 mm in diameter ovarian veins) [50]. Further highlighting the importance of MRV before intervention is a high Lower Extremity Chronic Venous Disease rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1].

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acrac_69507_19

Lower Extremity Chronic Venous Disease

In a study of 56 women with pelvic varicose veins, 44 patients demonstrated varying degrees of venous insufficiency. This information suggests a connection between pelvic varicose veins and venous insufficiency. Duplex US of the lower extremities may then be a very reasonable evaluation in patients with known pelvic varicose veins [51]. In addition, Khilnani et al [52] notes that duplex US in patients with varicose veins in the posterior thigh, vulva, and inguinal regions (nonsaphenous pelvic origin varicose veins) can help identify venous escape points from reflux in the internal iliac venous system. US Duplex Doppler Pelvis It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. If there are vulvar varicose veins, operators are rarely able to trace these vessels to a pelvic origin. These examinations require a very experienced sonographer to acquire relevant information. Most often, it is necessary to characterize with advanced imaging [1]. US Duplex Doppler IVC and Iliac Veins There is no relevant literature regarding the use of US for evaluation of the IVC and iliac veins in the treatment of pelvic-origin lower extremity varicose veins. As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44]. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities.

Lower Extremity Chronic Venous Disease. In a study of 56 women with pelvic varicose veins, 44 patients demonstrated varying degrees of venous insufficiency. This information suggests a connection between pelvic varicose veins and venous insufficiency. Duplex US of the lower extremities may then be a very reasonable evaluation in patients with known pelvic varicose veins [51]. In addition, Khilnani et al [52] notes that duplex US in patients with varicose veins in the posterior thigh, vulva, and inguinal regions (nonsaphenous pelvic origin varicose veins) can help identify venous escape points from reflux in the internal iliac venous system. US Duplex Doppler Pelvis It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common imaging technique because it is noninvasive. Evaluation should include direction of blood flow, assessment for venous reflux, and venous obstruction [20]. If there are vulvar varicose veins, operators are rarely able to trace these vessels to a pelvic origin. These examinations require a very experienced sonographer to acquire relevant information. Most often, it is necessary to characterize with advanced imaging [1]. US Duplex Doppler IVC and Iliac Veins There is no relevant literature regarding the use of US for evaluation of the IVC and iliac veins in the treatment of pelvic-origin lower extremity varicose veins. As in arterial vasculature, critical stenosis is defined by a sharp reduction in forward flow; in venous vasculature, critical stenosis is related to venous hypertension. In fact, the beneficial effects of venous stenting are related to peripheral venous decompression [44]. This is an important distinction to make because Doppler US can be used to evaluate for this metric via peak systolic velocities.

69507

acrac_69507_20

Lower Extremity Chronic Venous Disease

Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and monitor success of treatment on follow-up. Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment. Saphenous Vein Ablation Patients commonly present with lower extremity symptoms related to pelvic venous insufficiency. Typically after embolization and sclerotherapy of gonadal veins and pelvic varices, respectively, they may then have endovenous venous ablation of their saphenous veins for definitive treatment [56]. Compression Sclerotherapy Foam sclerotherapy is an option to treat chronic pelvic pain and pelvic-origin lower extremity varicose veins in women caused by a pelvic venous disorder, often in conjunction with embolization. Most of the current literature involves therapy of pelvic venous disease. Lower Extremity Chronic Venous Disease The commonly used substances reported in the literature for sclerotherapy are sodium tetradecyl sulfate and polidocanol. In high-flow pelvic varicoceles, there is a small risk of systemic dispersion of the sclerosant. In order to optimize the quantity and efficacy of the sclerosant, stop-flow foam sclerotherapy techniques have been described. This technique involves the use of balloon occlusion of high-outflow collaterals to achieve the complete filling of pelvic varices and exclusion of collaterals, thereby embolizing the entire length of incompetent vessels, including tributaries [57]. In a retrospective study of 26 patients involving the use of 3% sodium tetradecyl sulfate foam, significant improvement in symptoms was observed at 1, 3, 6, and 12 months. Of note, all patients had colic-like pain that spontaneously resolved after 5 minutes [58].

Lower Extremity Chronic Venous Disease. Labropoulos et al [45] and Metzger et al [46] agree that a peak systolic velocity ratio >2.5 across the stenosis (poststenotic velocity to prestenotic velocity) as an accurate criterion to use for the presence of a pressure gradient of 3 mm Hg. Doppler US can thus be used to determine candidacy for intervention and monitor success of treatment on follow-up. Variant 6: Pelvic-origin lower extremity varicose veins in females. Treatment. Saphenous Vein Ablation Patients commonly present with lower extremity symptoms related to pelvic venous insufficiency. Typically after embolization and sclerotherapy of gonadal veins and pelvic varices, respectively, they may then have endovenous venous ablation of their saphenous veins for definitive treatment [56]. Compression Sclerotherapy Foam sclerotherapy is an option to treat chronic pelvic pain and pelvic-origin lower extremity varicose veins in women caused by a pelvic venous disorder, often in conjunction with embolization. Most of the current literature involves therapy of pelvic venous disease. Lower Extremity Chronic Venous Disease The commonly used substances reported in the literature for sclerotherapy are sodium tetradecyl sulfate and polidocanol. In high-flow pelvic varicoceles, there is a small risk of systemic dispersion of the sclerosant. In order to optimize the quantity and efficacy of the sclerosant, stop-flow foam sclerotherapy techniques have been described. This technique involves the use of balloon occlusion of high-outflow collaterals to achieve the complete filling of pelvic varices and exclusion of collaterals, thereby embolizing the entire length of incompetent vessels, including tributaries [57]. In a retrospective study of 26 patients involving the use of 3% sodium tetradecyl sulfate foam, significant improvement in symptoms was observed at 1, 3, 6, and 12 months. Of note, all patients had colic-like pain that spontaneously resolved after 5 minutes [58].

69507

acrac_69507_21

Lower Extremity Chronic Venous Disease

In a meta-analysis of 21 prospective case series involving a total of 1,308 women, early substantial pain relief was observed in 75% of women undergoing embolization (including combinations of coil, glue, and sclerotherapy), generally increasing and sustained over time. Repeat interventions were generally low, and, although there were few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted. Overall, transient pain was common following foam embolization, and there was <2% risk of coil migration. Overall, data from studies that used a sclerosant suggest significant symptomatic improvement of approximately 75% [59]. Foam sclerotherapy has also shown good results as an alternative to embolization in patients with leg, vulvar, and pudendal varicosities of pelvic origin without pelvic venous disease [60]. Iliac Vein Stenting There is no relevant literature regarding the use of iliac stenting in the treatment of pelvic-origin lower extremity varicose veins in women, although it is postulated that stenting may relieve the congestion in the pelvis. However, there is no high-quality data. Iliac Vein Embolization Internal iliac vein embolization (in addition to ovarian vein embolization) has been shown to be safe and effective in treating pelvic venous insufficiency and reducing pelvic pain in most women undergoing treatment for pelvic congestion syndrome [61]. However, there is no high-quality data demonstrating the value of pelvic embolization or iliac or renal vein stenting to improve pelvic origin varicose veins and their related symptoms. Iliac Vein Surgery There is no relevant literature regarding the use of iliac vein surgery in the treatment of pelvic-origin lower extremity varicose veins in women. Left Renal Vein Stenting The treatment of pelvic venous disease due to nutcracker syndrome has been primarily surgical in the past, employing left renal vein bypass, transposition, and external stent placement.

Lower Extremity Chronic Venous Disease. In a meta-analysis of 21 prospective case series involving a total of 1,308 women, early substantial pain relief was observed in 75% of women undergoing embolization (including combinations of coil, glue, and sclerotherapy), generally increasing and sustained over time. Repeat interventions were generally low, and, although there were few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted. Overall, transient pain was common following foam embolization, and there was <2% risk of coil migration. Overall, data from studies that used a sclerosant suggest significant symptomatic improvement of approximately 75% [59]. Foam sclerotherapy has also shown good results as an alternative to embolization in patients with leg, vulvar, and pudendal varicosities of pelvic origin without pelvic venous disease [60]. Iliac Vein Stenting There is no relevant literature regarding the use of iliac stenting in the treatment of pelvic-origin lower extremity varicose veins in women, although it is postulated that stenting may relieve the congestion in the pelvis. However, there is no high-quality data. Iliac Vein Embolization Internal iliac vein embolization (in addition to ovarian vein embolization) has been shown to be safe and effective in treating pelvic venous insufficiency and reducing pelvic pain in most women undergoing treatment for pelvic congestion syndrome [61]. However, there is no high-quality data demonstrating the value of pelvic embolization or iliac or renal vein stenting to improve pelvic origin varicose veins and their related symptoms. Iliac Vein Surgery There is no relevant literature regarding the use of iliac vein surgery in the treatment of pelvic-origin lower extremity varicose veins in women. Left Renal Vein Stenting The treatment of pelvic venous disease due to nutcracker syndrome has been primarily surgical in the past, employing left renal vein bypass, transposition, and external stent placement.

69507

acrac_69507_22

Lower Extremity Chronic Venous Disease

However, because of the morbidity associated with surgical techniques, percutaneous endoluminal left renal vein stenting is now performed [62]. No studies have demonstrated benefit of renal vein stenting on pelvic origin lower extremity varicose veins. A limited number of studies have demonstrated remission of pelvic venous symptoms with stenting of the left renal vein as an alternative to open surgery [63], although none have demonstrated improvement in lower extremity varicose veins or symptoms. Left Renal Vein Surgery Though no literature has focused on nutcracker syndrome causing pelvic-derived varicose veins, the treatment of pelvic venous disease due to nutcracker syndrome has been primarily surgical in the past, employing left renal vein bypass, transposition, and external stent placement. However, because of the morbidity associated with surgical techniques, percutaneous endoluminal left renal vein stenting is increasingly performed [62]. Rundqvist et al [64] described the first open surgical removal of the left ovarian vein in patients with pelvic congestion syndrome. Symptomatic improvement was described in two-thirds of this studied cohort. Laparoscopic left ovarian vein surgical ligation in patients with pelvic congestion syndrome was described in 2003 by Gargiulo et al [65]; 23 out of 23 patients reported complete resolution of symptoms in the 1-year follow-up. No studies have demonstrated benefit of renal vein surgery on pelvic origin lower extremity varicose veins. Surgery should be considered in patients with lifestyle-limiting chronic pelvic pain that have recurred despite embolotherapy [63,66]. Lower Extremity Chronic Venous Disease Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of isolated pelvic-derived lower extremity varicose veins. However, it is well established as an effective tool at eliminating varicose veins in general and may be helpful in the correct clinical setting.

Lower Extremity Chronic Venous Disease. However, because of the morbidity associated with surgical techniques, percutaneous endoluminal left renal vein stenting is now performed [62]. No studies have demonstrated benefit of renal vein stenting on pelvic origin lower extremity varicose veins. A limited number of studies have demonstrated remission of pelvic venous symptoms with stenting of the left renal vein as an alternative to open surgery [63], although none have demonstrated improvement in lower extremity varicose veins or symptoms. Left Renal Vein Surgery Though no literature has focused on nutcracker syndrome causing pelvic-derived varicose veins, the treatment of pelvic venous disease due to nutcracker syndrome has been primarily surgical in the past, employing left renal vein bypass, transposition, and external stent placement. However, because of the morbidity associated with surgical techniques, percutaneous endoluminal left renal vein stenting is increasingly performed [62]. Rundqvist et al [64] described the first open surgical removal of the left ovarian vein in patients with pelvic congestion syndrome. Symptomatic improvement was described in two-thirds of this studied cohort. Laparoscopic left ovarian vein surgical ligation in patients with pelvic congestion syndrome was described in 2003 by Gargiulo et al [65]; 23 out of 23 patients reported complete resolution of symptoms in the 1-year follow-up. No studies have demonstrated benefit of renal vein surgery on pelvic origin lower extremity varicose veins. Surgery should be considered in patients with lifestyle-limiting chronic pelvic pain that have recurred despite embolotherapy [63,66]. Lower Extremity Chronic Venous Disease Microphlebectomy There is no relevant literature regarding the use of microphlebectomy in the treatment of isolated pelvic-derived lower extremity varicose veins. However, it is well established as an effective tool at eliminating varicose veins in general and may be helpful in the correct clinical setting.

69507

acrac_69507_23

Lower Extremity Chronic Venous Disease

Ovarian Vein Embolization Ovarian vein embolization is the most frequently cited treatment for pelvic venous disease, often in conjunction with sclerotherapy. In a meta-analysis of 21 prospective case series involving a total of 1,308 women, early substantial pain relief was observed in 75% of women undergoing embolization (including combinations of coil, glue, and sclerotherapy), generally increasing, and sustained over time. Repeat interventions were generally low, and, although there were few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted. Overall, transient pain was common following foam embolization, and there was <2% risk of coil migration. Overall, data from studies that used a sclerosant suggest significant symptomatic improvement of approximately 75% [59]. Immediate success rates for the endovascular treatment of pelvic venous disease have been favorable with the low complication rate. In a study, most patients reported pain relief in symptoms for up to 5 years post-treatment [67]. In a study involving 11 embolization procedures for 10 women (1 patient had an additional embolization procedure), 3 women (30%) had mild recurrence of pain at midterm follow-up. Of 8 patients who complained of dyspareunia, 6 were cured [68]. Evidence of efficacy in a second embolization procedure is contradictory. One study notes that embolization of pelvic varices may be an effective treatment in a well-selected group; however, if there is no improvement after the initial embolization, a second procedure is unlikely to be effective [69]. In a second study, 4 patients required second embolization, 3 of whom reported improved symptoms [70]. In another study involving retreatment after pregnancy-related recurrence, repeat embolization was shown to eliminate recurrent reflux [71]. Complications of embolization procedures have been noted in up to 9% of patients.

Lower Extremity Chronic Venous Disease. Ovarian Vein Embolization Ovarian vein embolization is the most frequently cited treatment for pelvic venous disease, often in conjunction with sclerotherapy. In a meta-analysis of 21 prospective case series involving a total of 1,308 women, early substantial pain relief was observed in 75% of women undergoing embolization (including combinations of coil, glue, and sclerotherapy), generally increasing, and sustained over time. Repeat interventions were generally low, and, although there were few data on post-treatment impact on menstruation, ovarian reserve, and fertility, no concerns were noted. Overall, transient pain was common following foam embolization, and there was <2% risk of coil migration. Overall, data from studies that used a sclerosant suggest significant symptomatic improvement of approximately 75% [59]. Immediate success rates for the endovascular treatment of pelvic venous disease have been favorable with the low complication rate. In a study, most patients reported pain relief in symptoms for up to 5 years post-treatment [67]. In a study involving 11 embolization procedures for 10 women (1 patient had an additional embolization procedure), 3 women (30%) had mild recurrence of pain at midterm follow-up. Of 8 patients who complained of dyspareunia, 6 were cured [68]. Evidence of efficacy in a second embolization procedure is contradictory. One study notes that embolization of pelvic varices may be an effective treatment in a well-selected group; however, if there is no improvement after the initial embolization, a second procedure is unlikely to be effective [69]. In a second study, 4 patients required second embolization, 3 of whom reported improved symptoms [70]. In another study involving retreatment after pregnancy-related recurrence, repeat embolization was shown to eliminate recurrent reflux [71]. Complications of embolization procedures have been noted in up to 9% of patients.

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acrac_69507_24

Lower Extremity Chronic Venous Disease

These include thrombophlebitis, embolization of nontarget vessels, recurrence varices, and stroke-related paradoxical emboli. Postembolization abdominal discomfort was reported in up to 14.8% of patients and is usually self-limited or treated with analgesic or anti-inflammatory medications [57]. Although success rates are favorable, excluding other causes such as nutcracker syndrome are important. Additionally, no randomized or high-quality controlled trials have been recorded, which limits the provided evidence. Though no gynecological complications were noted in the above literature, they have not been explicitly studied. No current prospective studies or randomized control trials demonstrating benefit of embolization for patients with pelvic-origin lower extremity varicose veins have been published. Current literature is limited to single-center case series which have failed to demonstrate significant improvement after pelvic venous embolization or stenting [52]. Overall, in distinction to ovarian vein embolization for patients with chronic pelvic pain, there is little evidence to support the use of embolization or stenting to aid in lower extremity pelvic origin varicose veins [52]. Conservative Management There is no relevant literature regarding the use of compression therapy in the treatment of pelvic-origin lower extremity varicose veins in women. Conservative therapies to manage symptoms of pelvic origin lower extremity varicose veins include compression therapy, nonsteroidal anti-inflammatory drugs, hormonal agents, ergot alkaloid derivatives, and venoactive agents [72]. Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as a diagnostic technique but is often now only performed as part of procedure with the intent to treat an iliocaval lesion.

Lower Extremity Chronic Venous Disease. These include thrombophlebitis, embolization of nontarget vessels, recurrence varices, and stroke-related paradoxical emboli. Postembolization abdominal discomfort was reported in up to 14.8% of patients and is usually self-limited or treated with analgesic or anti-inflammatory medications [57]. Although success rates are favorable, excluding other causes such as nutcracker syndrome are important. Additionally, no randomized or high-quality controlled trials have been recorded, which limits the provided evidence. Though no gynecological complications were noted in the above literature, they have not been explicitly studied. No current prospective studies or randomized control trials demonstrating benefit of embolization for patients with pelvic-origin lower extremity varicose veins have been published. Current literature is limited to single-center case series which have failed to demonstrate significant improvement after pelvic venous embolization or stenting [52]. Overall, in distinction to ovarian vein embolization for patients with chronic pelvic pain, there is little evidence to support the use of embolization or stenting to aid in lower extremity pelvic origin varicose veins [52]. Conservative Management There is no relevant literature regarding the use of compression therapy in the treatment of pelvic-origin lower extremity varicose veins in women. Conservative therapies to manage symptoms of pelvic origin lower extremity varicose veins include compression therapy, nonsteroidal anti-inflammatory drugs, hormonal agents, ergot alkaloid derivatives, and venoactive agents [72]. Variant 7: Suspected iliocaval or lower extremity disease with severe post-thrombotic changes. Initial diagnosis. Catheter Venography Iliac Veins Catheter-directed venography of the iliac veins has been described as a diagnostic technique but is often now only performed as part of procedure with the intent to treat an iliocaval lesion.

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acrac_69507_25

Lower Extremity Chronic Venous Disease

It is invasive, and in patients with post- thrombotic iliac and caval lesions, it is typically done after US/CTV/MRV has characterized an occlusion or stenosis [9]. Catheter venography with IVUS is usually performed in those with an indication for venous intervention, such as iliac vein stenting typically after CTV or MRV has characterized an occlusion or stenosis [6,9]. Lower Extremity Chronic Venous Disease Catheter Venography Lower Extremity Venography is performed mostly during procedures with the intent on treating an iliac or IVC obstructive lesion. Collaterals and post thrombotic changes from stenoses and/or occlusions are typically noted. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is very rarely used after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding anatomy could aid in the selection of appropriate treatment modality and reduce recurrence and complication rates. In a study, retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Characterization of these potential variants is important for treatment planning purposes. CTV Abdomen and Pelvis There are 2 scenarios described in the literature characterizing pelvic venous obstruction. Primary chronic venous disease describes a phenomenon in which there is obstruction in the pelvic or abdominal veins (eg, May-Thurner) without a prior DVT. Imaging can then be used to identify the cause of obstruction.

Lower Extremity Chronic Venous Disease. It is invasive, and in patients with post- thrombotic iliac and caval lesions, it is typically done after US/CTV/MRV has characterized an occlusion or stenosis [9]. Catheter venography with IVUS is usually performed in those with an indication for venous intervention, such as iliac vein stenting typically after CTV or MRV has characterized an occlusion or stenosis [6,9]. Lower Extremity Chronic Venous Disease Catheter Venography Lower Extremity Venography is performed mostly during procedures with the intent on treating an iliac or IVC obstructive lesion. Collaterals and post thrombotic changes from stenoses and/or occlusions are typically noted. CTV Lower Extremity CTV of the lower extremity has not been cited as a first-line examination. However, it is very rarely used after duplex US in evaluation for occlusion, stenosis, collaterals, post-thrombotic changes, and axial transformation of the profunda vein [8]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding anatomy could aid in the selection of appropriate treatment modality and reduce recurrence and complication rates. In a study, retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Characterization of these potential variants is important for treatment planning purposes. CTV Abdomen and Pelvis There are 2 scenarios described in the literature characterizing pelvic venous obstruction. Primary chronic venous disease describes a phenomenon in which there is obstruction in the pelvic or abdominal veins (eg, May-Thurner) without a prior DVT. Imaging can then be used to identify the cause of obstruction.

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acrac_69507_26

Lower Extremity Chronic Venous Disease

Secondary chronic venous disease describes a phenomenon in which primary thrombotic events cause a post-thrombotic syndrome. In addition to an occlusive IVC or iliac vein lesion, these cases also show signs of delayed or incomplete recanalization of the pelvic and lower extremity deep veins with extensive intraluminal changes. In both of the above types, primary focus should be on anatomy to accurately identify stenosis and occlusion related to outflow obstruction [9]. CTV of the abdomen and pelvis has been suggested in the literature in cases in which there are signs of iliac vein or IVC involvement, and in cases with fast recurrence of varicose veins after adequate treatment, CTV clearly identifies stenosis, occlusion, venous atresia, collaterals, and edema [9]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding anatomy could aid in the selection of appropriate treatment modality and reduce recurrence and complication rates. In this study, retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Characterization of these potential variants is important for treatment planning purposes. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific modality for deep vein obstructive disease. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. Catheter venography with IVUS should be performed in those with an indication for venous intervention such as iliac vein stenting [6]. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination.

Lower Extremity Chronic Venous Disease. Secondary chronic venous disease describes a phenomenon in which primary thrombotic events cause a post-thrombotic syndrome. In addition to an occlusive IVC or iliac vein lesion, these cases also show signs of delayed or incomplete recanalization of the pelvic and lower extremity deep veins with extensive intraluminal changes. In both of the above types, primary focus should be on anatomy to accurately identify stenosis and occlusion related to outflow obstruction [9]. CTV of the abdomen and pelvis has been suggested in the literature in cases in which there are signs of iliac vein or IVC involvement, and in cases with fast recurrence of varicose veins after adequate treatment, CTV clearly identifies stenosis, occlusion, venous atresia, collaterals, and edema [9]. Further highlighting the importance of CTV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Understanding anatomy could aid in the selection of appropriate treatment modality and reduce recurrence and complication rates. In this study, retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Characterization of these potential variants is important for treatment planning purposes. US Intravascular Iliac Veins IVUS has been cited as the most sensitive and specific modality for deep vein obstructive disease. Up to 10% of significant stenotic lesions, however, could not be seen via IVUS and required trial balloon angioplasty to unmask stenosis [8]. Catheter venography with IVUS should be performed in those with an indication for venous intervention such as iliac vein stenting [6]. MRV Lower Extremity MRV of the lower extremity has not been cited as a first-line examination.

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acrac_69507_27

Lower Extremity Chronic Venous Disease

As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy could aid in the selection of appropriate treatment modality and reduction of recurrence and complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Further highlighting the importance of MRV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Appropriate anatomic characterization before therapy can thus ensure appropriate and effective treatment [11-13]. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further highlighting the importance of MRV before intervention is a high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. Lower Extremity Chronic Venous Disease There are 2 scenarios described in the literature characterizing pelvic venous obstruction. Primary chronic venous disease describes a phenomenon in which there is obstruction in the pelvic or abdominal veins (eg, May-Thurner) without a prior DVT. Imaging can then be used to identify the cause of obstruction. Secondary chronic venous disease describes a phenomenon in which primary thrombotic events cause a post-thrombotic syndrome.

Lower Extremity Chronic Venous Disease. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Furthermore, understanding unique patient anatomy could aid in the selection of appropriate treatment modality and reduction of recurrence and complication rates. In a study, a retrospective evaluation of a prospectively acquired database, out of 810 studied limbs, there were numerous anatomic variations, including 1 anatomic variant that had not been described in the literature [11]. Further highlighting the importance of MRV before intervention is the high rate of recurrence 2 years postintervention (15%-35%). Appropriate anatomic characterization before therapy can thus ensure appropriate and effective treatment [11-13]. MRV Abdomen and Pelvis MRV of the abdomen and pelvis has not been cited as a first-line examination. As with CTV, MRV identifies stenosis, occlusion, venous atresia, collaterals, and edema. In addition, MRV can show webs, trabeculations, and vein wall thickening [9]. Further highlighting the importance of MRV before intervention is a high rate of recurrence 2 years postintervention (15%-35%). Further anatomic characterization before therapy can ensure appropriate and effective treatment [10-13]. Characterization of these potential variants is important for treatment planning purposes. Lower Extremity Chronic Venous Disease There are 2 scenarios described in the literature characterizing pelvic venous obstruction. Primary chronic venous disease describes a phenomenon in which there is obstruction in the pelvic or abdominal veins (eg, May-Thurner) without a prior DVT. Imaging can then be used to identify the cause of obstruction. Secondary chronic venous disease describes a phenomenon in which primary thrombotic events cause a post-thrombotic syndrome.

69507

acrac_69507_28

Lower Extremity Chronic Venous Disease

In addition to an occlusive IVC or iliac vein lesion, these cases also show signs of delayed or incomplete recanalization of the pelvic and lower extremity deep veins with extensive intraluminal changes. In both the above types, primary focus should be on anatomy to accurately identify stenosis and occlusion related to outflow obstruction [9]. Gadolinium-enhanced MRV with contrast seems to be the examination of choice because of the high intravascular enhancement and acquisition of isotropic voxels with a high spatial resolution allowing for evaluation of subtle changes. Three-dimensional volumetric imaging is preferred over MR direct thrombus or time-of-flight subtraction angiography because surrounding soft tissue should be visible to identify causes of stenosis or occlusion [9]. Pascarella and Shortell [6] believe that imaging of IVC and iliac veins when there is a history of persistent venous ulcers or duplex US evidence of iliocaval obstruction. These findings include diffuse venous reflux, nonphasic common femoral vein velocity spectral waveforms, and reduced flow augmentation with distal thigh compression. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common technique because of its noninvasiveness [20]. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1]. Though duplex US is widely considered the reference standard in evaluation of DVT, Hua et al [10] demonstrates that invasive preoperative venography is necessary before intervention to clarify the nature of disease and guide therapy. It is difficult to evaluate iliac vein involvement using this modality [73].

Lower Extremity Chronic Venous Disease. In addition to an occlusive IVC or iliac vein lesion, these cases also show signs of delayed or incomplete recanalization of the pelvic and lower extremity deep veins with extensive intraluminal changes. In both the above types, primary focus should be on anatomy to accurately identify stenosis and occlusion related to outflow obstruction [9]. Gadolinium-enhanced MRV with contrast seems to be the examination of choice because of the high intravascular enhancement and acquisition of isotropic voxels with a high spatial resolution allowing for evaluation of subtle changes. Three-dimensional volumetric imaging is preferred over MR direct thrombus or time-of-flight subtraction angiography because surrounding soft tissue should be visible to identify causes of stenosis or occlusion [9]. Pascarella and Shortell [6] believe that imaging of IVC and iliac veins when there is a history of persistent venous ulcers or duplex US evidence of iliocaval obstruction. These findings include diffuse venous reflux, nonphasic common femoral vein velocity spectral waveforms, and reduced flow augmentation with distal thigh compression. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common technique because of its noninvasiveness [20]. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1]. Though duplex US is widely considered the reference standard in evaluation of DVT, Hua et al [10] demonstrates that invasive preoperative venography is necessary before intervention to clarify the nature of disease and guide therapy. It is difficult to evaluate iliac vein involvement using this modality [73].

69507

acrac_69507_29

Lower Extremity Chronic Venous Disease

US Duplex Doppler IVC and Iliac Veins Because duplex US is noted as the first assessment of the lower extremity veins, it can also be used as means to determine patency of the IVC and iliac veins. A good quality examination with normal findings may obviate the need for further imaging. However, in some cases, visualization of the IVC and common iliac veins can be limited in some patients because of obesity or artifacts. Spectral waveforms can aid as an indirect means of assessing patency of the iliac veins or IVC. Evaluation of waveforms in the common femoral veins will show loss of respiratory phase variation and exhibit monophasic physiology with severe iliac vein occlusive disease with a high specificity but low sensitivity [74,75]. Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment. Anticoagulation The role of anticoagulation is most frequently noted in acute DVT [76]. In chronic DVT, anticoagulation also should have a pivotal role. Many patients with prior chronic DVT are at high risk for thrombosis, and these patients should be given therapeutic anticoagulation [77]. Because of the highly thrombotic environment, most of these patients should be given full dose anticoagulation throughout and immediately after recanalization procedures. Compression Therapy Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised,

Lower Extremity Chronic Venous Disease. US Duplex Doppler IVC and Iliac Veins Because duplex US is noted as the first assessment of the lower extremity veins, it can also be used as means to determine patency of the IVC and iliac veins. A good quality examination with normal findings may obviate the need for further imaging. However, in some cases, visualization of the IVC and common iliac veins can be limited in some patients because of obesity or artifacts. Spectral waveforms can aid as an indirect means of assessing patency of the iliac veins or IVC. Evaluation of waveforms in the common femoral veins will show loss of respiratory phase variation and exhibit monophasic physiology with severe iliac vein occlusive disease with a high specificity but low sensitivity [74,75]. Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment. Anticoagulation The role of anticoagulation is most frequently noted in acute DVT [76]. In chronic DVT, anticoagulation also should have a pivotal role. Many patients with prior chronic DVT are at high risk for thrombosis, and these patients should be given therapeutic anticoagulation [77]. Because of the highly thrombotic environment, most of these patients should be given full dose anticoagulation throughout and immediately after recanalization procedures. Compression Therapy Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised,

69507

acrac_69507_30

Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Endovascular Stenting In a randomized trial by Rossi et al [49], iliac vein stenting was shown to improve symptomatology and QoL compared with medical treatment alone. Thus, based on the morbidity of moderate to severe post-thrombotic syndrome and the available clinical studies and experience with iliac vein stenting for post-thrombotic syndrome treatment, endovascular stenting is a useful treatment [15]. Saphenous Vein Ablation There is no relevant literature regarding the use of saphenous ablation in the treatment of iliocaval or lower extremity post-thrombotic changes. Compression Sclerotherapy There is no relevant literature regarding the use of foam and compression sclerotherapy or cyanoacrylates in the treatment of iliocaval or lower extremity chronic DVT. Venous Angioplasty When recanalization of femoral and popliteal veins is performed because of chronic post-thrombotic changes, angioplasty is typically the first-line therapy. Stenting of femoral vein below the lesser trochanter and popliteal veins is not routinely performed because of an increased risk of in-stent thrombosis and occlusion [80,81]. Venous Bypass Procedure Surgical iliac vein reconstruction and variations of venous bypass have been reported. Endovascular options, as discussed above, have proven to be a viable alternative. Venous bypasses in the setting of iliocaval and lower extremity venous disease can be performed in situations in which minimally invasive or conservative options are unsuccessful. The clinical success and patency of these bypasses are poor (infrainguinal) and associated with significant postoperative morbidity (suprainguinal surgery). Poor patency is likely due to low velocity through the graft, external compression, inherent thrombus formation, and/or inadequate distal venous inflow [82].

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21]. Endovascular Stenting In a randomized trial by Rossi et al [49], iliac vein stenting was shown to improve symptomatology and QoL compared with medical treatment alone. Thus, based on the morbidity of moderate to severe post-thrombotic syndrome and the available clinical studies and experience with iliac vein stenting for post-thrombotic syndrome treatment, endovascular stenting is a useful treatment [15]. Saphenous Vein Ablation There is no relevant literature regarding the use of saphenous ablation in the treatment of iliocaval or lower extremity post-thrombotic changes. Compression Sclerotherapy There is no relevant literature regarding the use of foam and compression sclerotherapy or cyanoacrylates in the treatment of iliocaval or lower extremity chronic DVT. Venous Angioplasty When recanalization of femoral and popliteal veins is performed because of chronic post-thrombotic changes, angioplasty is typically the first-line therapy. Stenting of femoral vein below the lesser trochanter and popliteal veins is not routinely performed because of an increased risk of in-stent thrombosis and occlusion [80,81]. Venous Bypass Procedure Surgical iliac vein reconstruction and variations of venous bypass have been reported. Endovascular options, as discussed above, have proven to be a viable alternative. Venous bypasses in the setting of iliocaval and lower extremity venous disease can be performed in situations in which minimally invasive or conservative options are unsuccessful. The clinical success and patency of these bypasses are poor (infrainguinal) and associated with significant postoperative morbidity (suprainguinal surgery). Poor patency is likely due to low velocity through the graft, external compression, inherent thrombus formation, and/or inadequate distal venous inflow [82].

69507

acrac_69422_0

Chronic Ankle Pain

Introduction/Background Ankle pain is considered chronic when symptoms persist >6 weeks. Chronic ankle pain can be caused by a variety of osseous or soft-tissue abnormalities, either alone or in combination. For assessing chronic ankle pain, there are multiple imaging options, including radiography, stress radiography, computed tomography (CT) radionuclide bone scanning, ultrasound (US), magnetic resonance imaging (MRI), and various injection procedures. Injection procedures include arthrography, CT arthrography, MR arthrography, and diagnostic injection with anesthetic agents. Although there are numerous causes for chronic ankle pain, common etiologies include osteoarthritis, osteochondral injury, tendon abnormalities, ligament abnormalities and instability, and impingement. Overview of Imaging Modalities Radiography Radiographs can provide information about the osseous and soft-tissue structures about the ankle. Routine radiographs of the ankle typically include anteroposterior, lateral, and mortise views, the latter obtained by internally rotating the foot 15 to 20 degrees. Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. CT CT CT is not routinely used as a first-line imaging tool in chronic ankle pain, but it is more sensitive than radiographs, particularly for osseous abnormalities [5]. CT arthrography may be more accurate than MR arthrography for the identification of osteochondral abnormalities [6]. Bone Scan Conventional planar bone scintigraphy can assess osseous pathology. More recently, single-photon emission computed tomography (SPECT) combined with CT has been shown to provide additional information compared with clinical diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft- tissue pathology [7]. In addition, SPECT/CT abnormalities have been shown to significantly correlate with pain in osteochondral lesions [8].

Chronic Ankle Pain. Introduction/Background Ankle pain is considered chronic when symptoms persist >6 weeks. Chronic ankle pain can be caused by a variety of osseous or soft-tissue abnormalities, either alone or in combination. For assessing chronic ankle pain, there are multiple imaging options, including radiography, stress radiography, computed tomography (CT) radionuclide bone scanning, ultrasound (US), magnetic resonance imaging (MRI), and various injection procedures. Injection procedures include arthrography, CT arthrography, MR arthrography, and diagnostic injection with anesthetic agents. Although there are numerous causes for chronic ankle pain, common etiologies include osteoarthritis, osteochondral injury, tendon abnormalities, ligament abnormalities and instability, and impingement. Overview of Imaging Modalities Radiography Radiographs can provide information about the osseous and soft-tissue structures about the ankle. Routine radiographs of the ankle typically include anteroposterior, lateral, and mortise views, the latter obtained by internally rotating the foot 15 to 20 degrees. Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. CT CT CT is not routinely used as a first-line imaging tool in chronic ankle pain, but it is more sensitive than radiographs, particularly for osseous abnormalities [5]. CT arthrography may be more accurate than MR arthrography for the identification of osteochondral abnormalities [6]. Bone Scan Conventional planar bone scintigraphy can assess osseous pathology. More recently, single-photon emission computed tomography (SPECT) combined with CT has been shown to provide additional information compared with clinical diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft- tissue pathology [7]. In addition, SPECT/CT abnormalities have been shown to significantly correlate with pain in osteochondral lesions [8].

69422

acrac_69422_1

Chronic Ankle Pain

US US can be used to evaluate for soft-tissue abnormalities, including tendon and ligament tears. In inflammatory arthritis, it can help in the assessment of disease activity and severity as well as detect subclinical pathology in early disease or after treatment [9]. US is ideal for dynamic assessment of peroneal tendon instability [10] and can be used to guide interventions [11]. Compared with some other modalities, US is less prone to artifacts, such as susceptibility, motion, magic angle, and streak artifact, but dynamic assessment may be limited in cases of pain. MRI MRI is the imaging test that globally evaluates all anatomic structures, including ligaments, tendons, cartilage, and bone [12,13]. Most studies have shown that MRI is highly accurate for evaluation of ligament, tendon, and 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: publications@acr.org Chronic Ankle Pain osteochondral abnormalities [14-16], although one study found statistically significant lower sensitivity for these abnormalities on MRI as compared to arthroscopy [17]. MRI can identify synovitis and impingement lesions, which can contribute to patient symptoms [18]. Discussion of Procedures by Variant Variant 1: Chronic ankle pain. Initial imaging. Radiography Radiography should be considered as the initial imaging study. Radiographs may reveal osteoarthritis, calcified or ossified intra-articular bodies, osteochondral abnormalities, stress fractures, or evidence of prior trauma. Ankle effusions may also be identified in the anterior ankle joint recess by radiography with 53% to 74% accuracy [19]. They are often associated with ligamentous injury or fracture [19].

Chronic Ankle Pain. US US can be used to evaluate for soft-tissue abnormalities, including tendon and ligament tears. In inflammatory arthritis, it can help in the assessment of disease activity and severity as well as detect subclinical pathology in early disease or after treatment [9]. US is ideal for dynamic assessment of peroneal tendon instability [10] and can be used to guide interventions [11]. Compared with some other modalities, US is less prone to artifacts, such as susceptibility, motion, magic angle, and streak artifact, but dynamic assessment may be limited in cases of pain. MRI MRI is the imaging test that globally evaluates all anatomic structures, including ligaments, tendons, cartilage, and bone [12,13]. Most studies have shown that MRI is highly accurate for evaluation of ligament, tendon, and 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: publications@acr.org Chronic Ankle Pain osteochondral abnormalities [14-16], although one study found statistically significant lower sensitivity for these abnormalities on MRI as compared to arthroscopy [17]. MRI can identify synovitis and impingement lesions, which can contribute to patient symptoms [18]. Discussion of Procedures by Variant Variant 1: Chronic ankle pain. Initial imaging. Radiography Radiography should be considered as the initial imaging study. Radiographs may reveal osteoarthritis, calcified or ossified intra-articular bodies, osteochondral abnormalities, stress fractures, or evidence of prior trauma. Ankle effusions may also be identified in the anterior ankle joint recess by radiography with 53% to 74% accuracy [19]. They are often associated with ligamentous injury or fracture [19].

69422

acrac_69422_2

Chronic Ankle Pain

The presence of ossific fragments can indicate ligamentous injury or retinaculum avulsion [20], whereas periostitis can occur adjacent to tenosynovitis. Radiographs can also identify synovial osteochondromatosis and erosions from chronic synovitis. CT CT is not routinely used as the first study for the evaluation of chronic ankle pain. MRI MRI MRI is not routinely used as the first study for the evaluation of chronic ankle pain. US US US is not routinely used as the first study for the evaluation of chronic ankle pain. Bone Scan Bone scan is not routinely used as the first study for the evaluation of chronic ankle pain. Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study. When multiple sites of osteoarthritis are present, it may be important to determine which joint is the cause of symptoms. Image-guided Anesthetic Injection Several reports have indicated the effectiveness of fluoroscopic, CT, or US-guided anesthetic [11] with or without corticosteroid injection of joints to identify a source of pain, which aids in surgical planning [21-25]. MRI When degenerative changes of the ankle joint are diagnosed based on radiographs, MRI may be considered as the next best examination to evaluate cartilage integrity, bone marrow, and associated soft tissues, such as ligaments and tendons, if these injuries are clinically suspected [13-15]. CT CT CT without contrast may be helpful to visualize subchondral cysts [5]. US US is not routinely used for the evaluation of degenerative joint disease. Bone Scan Bone scan is not routinely used for the evaluation of degenerative joint disease. Arthrography Arthrography is not routinely used for the evaluation of degenerative joint disease. MR Arthrography MR arthrography is not routinely used for the evaluation of degenerative joint disease. CT Arthrography CT arthrography is not routinely used for the evaluation of degenerative joint disease. Variant 3: Chronic ankle pain.

Chronic Ankle Pain. The presence of ossific fragments can indicate ligamentous injury or retinaculum avulsion [20], whereas periostitis can occur adjacent to tenosynovitis. Radiographs can also identify synovial osteochondromatosis and erosions from chronic synovitis. CT CT is not routinely used as the first study for the evaluation of chronic ankle pain. MRI MRI MRI is not routinely used as the first study for the evaluation of chronic ankle pain. US US US is not routinely used as the first study for the evaluation of chronic ankle pain. Bone Scan Bone scan is not routinely used as the first study for the evaluation of chronic ankle pain. Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study. When multiple sites of osteoarthritis are present, it may be important to determine which joint is the cause of symptoms. Image-guided Anesthetic Injection Several reports have indicated the effectiveness of fluoroscopic, CT, or US-guided anesthetic [11] with or without corticosteroid injection of joints to identify a source of pain, which aids in surgical planning [21-25]. MRI When degenerative changes of the ankle joint are diagnosed based on radiographs, MRI may be considered as the next best examination to evaluate cartilage integrity, bone marrow, and associated soft tissues, such as ligaments and tendons, if these injuries are clinically suspected [13-15]. CT CT CT without contrast may be helpful to visualize subchondral cysts [5]. US US is not routinely used for the evaluation of degenerative joint disease. Bone Scan Bone scan is not routinely used for the evaluation of degenerative joint disease. Arthrography Arthrography is not routinely used for the evaluation of degenerative joint disease. MR Arthrography MR arthrography is not routinely used for the evaluation of degenerative joint disease. CT Arthrography CT arthrography is not routinely used for the evaluation of degenerative joint disease. Variant 3: Chronic ankle pain.

69422

acrac_69422_3

Chronic Ankle Pain

Ankle radiographs normal, suspected osteochondral lesion. Next study. Osteochondral injuries may involve the talar dome and, less commonly, the tibial plafond and tarsal navicular bone [5,26,27]. If this injury is associated with fracture, osseous cyst, or osteochondral defect, radiography may show the abnormality; however, radiography often fails to show the extent of the osteochondral injury and will be Chronic Ankle Pain initially negative if the injury is limited to the articular hyaline cartilage. One multimodality study [5] showed that 41% of osteochondral abnormalities of the ankle were missed on radiography. MRI In one multimodality study, MRI performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. Although MRI had the highest sensitivity (96%), it was less specific than CT [5]. MRI is effective in determining osteochondral injury instability (sensitivity 97%), most commonly appearing as a high signal line deep to the osteochondral lesion on T2-weighted images or less commonly as a focal defect, an articular fracture, or an adjacent cyst [28]. MRI has also been used to stage these lesions preoperatively with an accuracy of 81% [29] and to assess osteochondral abnormalities after cartilage repair [30]. Although MRI may be less reliable than CT arthrography for talar cartilaginous lesions (accuracy between 76% to 88%) [6], high- resolution MRI using a microscopy coil (eg, a 4-cm receive-only surface coil) can assist in detecting small, clinically relevant features of talar osteochondral lesions that may be missed on standard MRI, including osteochondral junction separation due to focal collapse of the subchondral bone, reparative cartilage hypertrophy, and bone separation in the absence of cartilage fracture [31]. CT Arthrography The introduction of contrast into the ankle joint prior to CT will outline a cartilage surface defect, assisting in lesion detection and assessment for instability.

Chronic Ankle Pain. Ankle radiographs normal, suspected osteochondral lesion. Next study. Osteochondral injuries may involve the talar dome and, less commonly, the tibial plafond and tarsal navicular bone [5,26,27]. If this injury is associated with fracture, osseous cyst, or osteochondral defect, radiography may show the abnormality; however, radiography often fails to show the extent of the osteochondral injury and will be Chronic Ankle Pain initially negative if the injury is limited to the articular hyaline cartilage. One multimodality study [5] showed that 41% of osteochondral abnormalities of the ankle were missed on radiography. MRI In one multimodality study, MRI performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. Although MRI had the highest sensitivity (96%), it was less specific than CT [5]. MRI is effective in determining osteochondral injury instability (sensitivity 97%), most commonly appearing as a high signal line deep to the osteochondral lesion on T2-weighted images or less commonly as a focal defect, an articular fracture, or an adjacent cyst [28]. MRI has also been used to stage these lesions preoperatively with an accuracy of 81% [29] and to assess osteochondral abnormalities after cartilage repair [30]. Although MRI may be less reliable than CT arthrography for talar cartilaginous lesions (accuracy between 76% to 88%) [6], high- resolution MRI using a microscopy coil (eg, a 4-cm receive-only surface coil) can assist in detecting small, clinically relevant features of talar osteochondral lesions that may be missed on standard MRI, including osteochondral junction separation due to focal collapse of the subchondral bone, reparative cartilage hypertrophy, and bone separation in the absence of cartilage fracture [31]. CT Arthrography The introduction of contrast into the ankle joint prior to CT will outline a cartilage surface defect, assisting in lesion detection and assessment for instability.

69422

acrac_69422_4

Chronic Ankle Pain

One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an accuracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6]. MR Arthrography The introduction of contrast into the ankle joint prior to MRI will outline a cartilage surface defect, assisting in lesion detection and assessment for instability. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an accuracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6]. CT In one multimodality study, CT (noncontrast, multidetector with multiplanar reformatted images) performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. However, CT was more specific (99%) but less sensitive then MRI [5]. US US is not routinely used for the evaluation of osteochondral lesions in the ankle. Radiography Stress views are not routinely used for the evaluation of osteochondral lesions in the ankle. Arthrography Arthrography is not routinely used for the evaluation of osteochondral lesions in the ankle. Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study. Possible tendon abnormalities include tenosynovitis, tendinopathy, tendon tear (partial or complete), and tendon subluxation or dislocation. Both MRI and US can effectively demonstrate ankle tendon abnormalities, although US results are more dependent on operator skill and expertise [10,35]. For the assessment, it is assumed the procedure is performed and interpreted by an expert. Chronic Ankle Pain US US can be used to evaluate for soft-tissue abnormalities, including tendon and ligament tears.

Chronic Ankle Pain. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an accuracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6]. MR Arthrography The introduction of contrast into the ankle joint prior to MRI will outline a cartilage surface defect, assisting in lesion detection and assessment for instability. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an accuracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6]. CT In one multimodality study, CT (noncontrast, multidetector with multiplanar reformatted images) performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. However, CT was more specific (99%) but less sensitive then MRI [5]. US US is not routinely used for the evaluation of osteochondral lesions in the ankle. Radiography Stress views are not routinely used for the evaluation of osteochondral lesions in the ankle. Arthrography Arthrography is not routinely used for the evaluation of osteochondral lesions in the ankle. Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study. Possible tendon abnormalities include tenosynovitis, tendinopathy, tendon tear (partial or complete), and tendon subluxation or dislocation. Both MRI and US can effectively demonstrate ankle tendon abnormalities, although US results are more dependent on operator skill and expertise [10,35]. For the assessment, it is assumed the procedure is performed and interpreted by an expert. Chronic Ankle Pain US US can be used to evaluate for soft-tissue abnormalities, including tendon and ligament tears.

69422

acrac_69422_5

Chronic Ankle Pain

It has been shown to produce similar results as MRI in diagnosing ankle tendon tears, although US results are more dependent on operator skill and expertise [10,35]. In this case, it is assumed that the procedure is performed and interpreted by an expert. One study showed that it had a sensitivity of 100% and an accuracy of 93% compared to surgical findings [36]. With regard to the tibialis posterior tendon, one study evaluating tendon pathology showed that US was slightly less sensitive than MRI; however, this difference did not significantly affect clinical management [37]. One study using US showed 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears [38]; suggesting that US may be more useful than MRI. With regard to chronic Achilles tendinopathy, US detected 21 of 26 cases of tendinosis and partial rupture [39], and another study showed that US can differentiate full- thickness from partial-thickness Achilles tears with 92% accuracy [40]. In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, it can be used to guide interventions such as concurrent performance of US-guided intrasheath anesthetic injections [11]. It can also be used for direct intratendinous biologic injection and dry needling [41-43]. One significant advantage of US is in the dynamic assessment for tendon subluxation (including intrasheath subluxation) and dislocation, with a reported positive predictive value of 100% compared to surgical findings [44,45]. US-guided sheath injections are more accurate than palpation guided and allow for precise positioning of the needle tip in the sheath rather than the tendon substance because a large volume intratendinous injection of corticosteroids or local anesthetic can result in a split tear [46]. US can detect intratendinous tophi in gout, enthesitis of the Achilles tendon or plantar fascia in spondyloarthritis, and tenosynovitis in spondyloarthritis and rheumatoid arthritis [47].

Chronic Ankle Pain. It has been shown to produce similar results as MRI in diagnosing ankle tendon tears, although US results are more dependent on operator skill and expertise [10,35]. In this case, it is assumed that the procedure is performed and interpreted by an expert. One study showed that it had a sensitivity of 100% and an accuracy of 93% compared to surgical findings [36]. With regard to the tibialis posterior tendon, one study evaluating tendon pathology showed that US was slightly less sensitive than MRI; however, this difference did not significantly affect clinical management [37]. One study using US showed 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears [38]; suggesting that US may be more useful than MRI. With regard to chronic Achilles tendinopathy, US detected 21 of 26 cases of tendinosis and partial rupture [39], and another study showed that US can differentiate full- thickness from partial-thickness Achilles tears with 92% accuracy [40]. In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, it can be used to guide interventions such as concurrent performance of US-guided intrasheath anesthetic injections [11]. It can also be used for direct intratendinous biologic injection and dry needling [41-43]. One significant advantage of US is in the dynamic assessment for tendon subluxation (including intrasheath subluxation) and dislocation, with a reported positive predictive value of 100% compared to surgical findings [44,45]. US-guided sheath injections are more accurate than palpation guided and allow for precise positioning of the needle tip in the sheath rather than the tendon substance because a large volume intratendinous injection of corticosteroids or local anesthetic can result in a split tear [46]. US can detect intratendinous tophi in gout, enthesitis of the Achilles tendon or plantar fascia in spondyloarthritis, and tenosynovitis in spondyloarthritis and rheumatoid arthritis [47].

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acrac_69422_6

Chronic Ankle Pain

MRI It is generally accepted that MRI can achieve high sensitivities (>90%) in diagnosing ankle tendon tears [16]. Regarding tibialis posterior tendon, MRI is more sensitive than US; however, this difference did not significantly affect clinical management [37]. With regard to peroneal tendinopathy and tendon tear, one study found the sensitivities and specificities of MRI to be 83.9% and 74.5%, respectively, for tendinopathy and 54.5% and 88.7%, respectively, for tendon tears [48]. With regard to chronic Achilles tendinopathy, MRI detected 26 of 27 cases of tendinosis and partial rupture [39]. MRI reported a 66% accuracy rate for assessment for tendon subluxation and dislocation [44,45]. MRI evidence of peroneal tendon pathology should be treated with caution because up to 34% of asymptomatic patients may have a tear of the peroneus brevis tendon [49]. One study showed that MRI evidence of peroneal tendon pathology had a 48% positive predictive value for clinical findings, highlighting the importance of clinical examination [50]. Image-guided Anesthetic Injection In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, a fluoroscopic or US- guided intrasheath anesthetic injection can be concurrently performed [11]. Tenography Diagnostic and therapeutic ankle tenography can also be considered for evaluation, with one study reporting that 47% of patients had prolonged relief of symptoms [51]. CT CT is not routinely used for the evaluation of suspected tendon abnormality. Bone Scan Bone scan is not routinely used for the evaluation of suspected tendon abnormality. CT Arthrography CT arthrography is not routinely used for the evaluation of suspected tendon abnormality. MR Arthrography MR arthrography is not routinely used for the evaluation of suspected tendon abnormality. Arthrography Arthrography is not routinely used for the evaluation of suspected tendon abnormality. Chronic Ankle Pain

Chronic Ankle Pain. MRI It is generally accepted that MRI can achieve high sensitivities (>90%) in diagnosing ankle tendon tears [16]. Regarding tibialis posterior tendon, MRI is more sensitive than US; however, this difference did not significantly affect clinical management [37]. With regard to peroneal tendinopathy and tendon tear, one study found the sensitivities and specificities of MRI to be 83.9% and 74.5%, respectively, for tendinopathy and 54.5% and 88.7%, respectively, for tendon tears [48]. With regard to chronic Achilles tendinopathy, MRI detected 26 of 27 cases of tendinosis and partial rupture [39]. MRI reported a 66% accuracy rate for assessment for tendon subluxation and dislocation [44,45]. MRI evidence of peroneal tendon pathology should be treated with caution because up to 34% of asymptomatic patients may have a tear of the peroneus brevis tendon [49]. One study showed that MRI evidence of peroneal tendon pathology had a 48% positive predictive value for clinical findings, highlighting the importance of clinical examination [50]. Image-guided Anesthetic Injection In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, a fluoroscopic or US- guided intrasheath anesthetic injection can be concurrently performed [11]. Tenography Diagnostic and therapeutic ankle tenography can also be considered for evaluation, with one study reporting that 47% of patients had prolonged relief of symptoms [51]. CT CT is not routinely used for the evaluation of suspected tendon abnormality. Bone Scan Bone scan is not routinely used for the evaluation of suspected tendon abnormality. CT Arthrography CT arthrography is not routinely used for the evaluation of suspected tendon abnormality. MR Arthrography MR arthrography is not routinely used for the evaluation of suspected tendon abnormality. Arthrography Arthrography is not routinely used for the evaluation of suspected tendon abnormality. Chronic Ankle Pain

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acrac_69422_7

Chronic Ankle Pain

Radiography Stress views are not routinely used for the evaluation of suspected tendon abnormality. Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study. In the absence of findings on routine radiography, imaging options to evaluate ligamentous integrity include stress radiography, MRI, MR arthrography, CT arthrography, and US. MRI One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 97% for MRI when compared to arthroscopic findings. Additionally, MRI identified the exact location of the injury in 93% of the cases [15]. Comparing MRI with arthroscopy, studies have shown a range of accuracies of chronic lateral ligament tearing (either partial or complete), ranging from 77% to 92% for the anterior talofibular ligament and 88% to 92% for the calcaneofibular ligament [14,52]. For the evaluation of deep deltoid ligament tears, MRI is both sensitive and specific compared with arthroscopy, with reported values of 96% and 98%, respectively [53]. With regard to tears of the tibiofibular ligaments of the tibiofibular syndesmosis, MRI has a reported accuracy of 100% [54]. Additionally, MRI can also demonstrate interosseous membrane tears [55]. MRI offers the advantage of evaluating for injuries associated with or mimicking lateral instability that may not be diagnosed on stress radiography such as tenosynovitis, tendon injury, and osteochondral lesions [56]. MRI may also be used to evaluate the ankle after lateral ligament reconstruction [57]. MR Arthrography MR arthrography can be helpful for the assessment of chronic ankle instability due to lateral collateral ligament injuries [12]. US One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 91% for US when compared to arthroscopic findings. Additionally, US identified the exact location of the injury in 63% of cases [15].

Chronic Ankle Pain. Radiography Stress views are not routinely used for the evaluation of suspected tendon abnormality. Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study. In the absence of findings on routine radiography, imaging options to evaluate ligamentous integrity include stress radiography, MRI, MR arthrography, CT arthrography, and US. MRI One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 97% for MRI when compared to arthroscopic findings. Additionally, MRI identified the exact location of the injury in 93% of the cases [15]. Comparing MRI with arthroscopy, studies have shown a range of accuracies of chronic lateral ligament tearing (either partial or complete), ranging from 77% to 92% for the anterior talofibular ligament and 88% to 92% for the calcaneofibular ligament [14,52]. For the evaluation of deep deltoid ligament tears, MRI is both sensitive and specific compared with arthroscopy, with reported values of 96% and 98%, respectively [53]. With regard to tears of the tibiofibular ligaments of the tibiofibular syndesmosis, MRI has a reported accuracy of 100% [54]. Additionally, MRI can also demonstrate interosseous membrane tears [55]. MRI offers the advantage of evaluating for injuries associated with or mimicking lateral instability that may not be diagnosed on stress radiography such as tenosynovitis, tendon injury, and osteochondral lesions [56]. MRI may also be used to evaluate the ankle after lateral ligament reconstruction [57]. MR Arthrography MR arthrography can be helpful for the assessment of chronic ankle instability due to lateral collateral ligament injuries [12]. US One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 91% for US when compared to arthroscopic findings. Additionally, US identified the exact location of the injury in 63% of cases [15].

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acrac_69422_8

Chronic Ankle Pain

Another study comparing US and CT arthrography for the diagnosis of anterior talofibular ligament injury showed an accuracy of 61% using US and 71% for CT arthrography [58]. US also has the dynamic capability of stressing the ligament and looking for laxity or frank separation of the injured ligament [1,59]. With regard to interosseous membrane tears, US has a proven sensitivity of 89% and specificity of 94.5% in diagnosing interosseous membrane tears shown at surgery [55,60]. Radiography Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 67% for stress radiography [15]. Oae et al [15] compared stress radiography to arthroscopic findings and found the former has an accuracy of 67% for evaluating anterior talofibular ligament injuries. Subtalar stress radiography using forced dorsiflexion and supination [4] or talar rotation [61] can be used to evaluate subtalar laxity. CT Arthrography CT arthrography showed an accuracy of 71% for diagnosing anterior talofibular ligament injury [58]. CT CT CT is not routinely used for the evaluation of ligamentous integrity. Arthrography Arthrography is not routinely used for the evaluation of ligamentous integrity. Image-guided Anesthetic Injection Image-guided anesthetic injection is not routinely used for the evaluation of ligamentous integrity. Bone Scan Bone scan is not routinely used for the evaluation of ligamentous integrity. Chronic Ankle Pain Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study. Imaging can also be used to diagnose ankle impingement syndromes, which can occur in the anterolateral, anterior, anteromedial, posteromedial, and posterior aspects of the ankle joint [62-71].

Chronic Ankle Pain. Another study comparing US and CT arthrography for the diagnosis of anterior talofibular ligament injury showed an accuracy of 61% using US and 71% for CT arthrography [58]. US also has the dynamic capability of stressing the ligament and looking for laxity or frank separation of the injured ligament [1,59]. With regard to interosseous membrane tears, US has a proven sensitivity of 89% and specificity of 94.5% in diagnosing interosseous membrane tears shown at surgery [55,60]. Radiography Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 67% for stress radiography [15]. Oae et al [15] compared stress radiography to arthroscopic findings and found the former has an accuracy of 67% for evaluating anterior talofibular ligament injuries. Subtalar stress radiography using forced dorsiflexion and supination [4] or talar rotation [61] can be used to evaluate subtalar laxity. CT Arthrography CT arthrography showed an accuracy of 71% for diagnosing anterior talofibular ligament injury [58]. CT CT CT is not routinely used for the evaluation of ligamentous integrity. Arthrography Arthrography is not routinely used for the evaluation of ligamentous integrity. Image-guided Anesthetic Injection Image-guided anesthetic injection is not routinely used for the evaluation of ligamentous integrity. Bone Scan Bone scan is not routinely used for the evaluation of ligamentous integrity. Chronic Ankle Pain Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study. Imaging can also be used to diagnose ankle impingement syndromes, which can occur in the anterolateral, anterior, anteromedial, posteromedial, and posterior aspects of the ankle joint [62-71].

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acrac_69422_9

Chronic Ankle Pain

MR Arthrography MR arthrography has been found to be an accurate method for assessing both anterolateral and anteromedial impingement with the advantage of joint capsule distention by intra-articular contrast injection [68,69]. US One study involving anterolateral ankle impingement compared US to arthroscopic findings. The study found US had a sensitivity and specificity of 77% and 57%, respectively [70]. US also showed abnormal soft tissues in anterolateral impingement, with a reported accuracy of 100% in one study [72]. MRI Studies on the accuracy of MRI in diagnosing anterolateral impingement syndrome have drawn varying conclusions, which may be related to varying MRI magnet strengths and inconsistent protocols [73]. Comparing MRI with surgical findings, studies have shown sensitivities between 75% to 83% and specificity between 75% to 100% for the diagnosis of anterolateral impingement [73,74]. One study found that, when compared with arthroscopy, fat-suppressed, IV contrast-enhanced, 3-D gradient- recalled echo imaging was sensitive for the evaluation of synovitis of the ankle associated with trauma (92%), whereas it was specific for soft-tissue impingement evaluation (97%) when the ankle was divided into four compartments: the anterolateral gutter, anteromedial gutter, anterior recess, and posterior recess [75]. MRI is useful in confirming the diagnosis, evaluating patients with an uncertain clinical diagnosis, and planning surgery. Additionally, it can help exclude other pathologic entities that may mimic or coexist with impingement syndromes. However, MRI features supportive of impingement may be present in asymptomatic individuals, and an accurate diagnosis requires careful correlation of imaging features findings with clinical findings [76]. There are only limited reports on the use of MRI for the other forms of ankle impingement syndrome, so its accuracy in these conditions is not well established [62,64,67,68].

Chronic Ankle Pain. MR Arthrography MR arthrography has been found to be an accurate method for assessing both anterolateral and anteromedial impingement with the advantage of joint capsule distention by intra-articular contrast injection [68,69]. US One study involving anterolateral ankle impingement compared US to arthroscopic findings. The study found US had a sensitivity and specificity of 77% and 57%, respectively [70]. US also showed abnormal soft tissues in anterolateral impingement, with a reported accuracy of 100% in one study [72]. MRI Studies on the accuracy of MRI in diagnosing anterolateral impingement syndrome have drawn varying conclusions, which may be related to varying MRI magnet strengths and inconsistent protocols [73]. Comparing MRI with surgical findings, studies have shown sensitivities between 75% to 83% and specificity between 75% to 100% for the diagnosis of anterolateral impingement [73,74]. One study found that, when compared with arthroscopy, fat-suppressed, IV contrast-enhanced, 3-D gradient- recalled echo imaging was sensitive for the evaluation of synovitis of the ankle associated with trauma (92%), whereas it was specific for soft-tissue impingement evaluation (97%) when the ankle was divided into four compartments: the anterolateral gutter, anteromedial gutter, anterior recess, and posterior recess [75]. MRI is useful in confirming the diagnosis, evaluating patients with an uncertain clinical diagnosis, and planning surgery. Additionally, it can help exclude other pathologic entities that may mimic or coexist with impingement syndromes. However, MRI features supportive of impingement may be present in asymptomatic individuals, and an accurate diagnosis requires careful correlation of imaging features findings with clinical findings [76]. There are only limited reports on the use of MRI for the other forms of ankle impingement syndrome, so its accuracy in these conditions is not well established [62,64,67,68].

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acrac_69422_10

Chronic Ankle Pain

CT Arthrography One study involving anterolateral ankle impingement compared CT arthrography to arthroscopic findings. The study found that CT arthrography had a sensitivity and specificity of 97% and 71%, respectively [77]. Image-guided Anesthetic Injection Fluoroscopic or US-guided injections have been shown as an effective treatment for some ankle impingement syndromes [78,79]. Bone Scan with SPECT or SPECT/CT Recently, SPECT combined with CT has been shown to provide additional information compared with clinical diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft-tissue pathology [7]. One study found that SPECT/CT provided information not suspected on clinical diagnosis in 56% of cases with impingement syndromes or soft-tissue pathology [7]. CT CT CT may be useful for depiction of osseous causes of impingement, such as chronic abnormalities between the talus and an os trigonum or fractures of the lateral tubercle of the talus or os trigonum [62]. Arthrography Arthrography is not routinely used for the evaluation of ankle impingement syndromes. Radiography Stress views are not routinely used for the evaluation of ankle impingement syndromes. Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study. When chronic ankle pain is of unclear etiology, normal ankle radiographs can be followed by other imaging tests, primarily directed by clinical findings. Chronic Ankle Pain MRI If the patient has a focal soft-tissue abnormality, MRI can be considered. Peripheral nerve-related symptoms can be evaluated with US or MRI; however, US has the benefit of higher resolution. If symptoms are believed to originate from osseous structures, MRI can be considered if there is concern for an initially missed fracture [80]. MRI is effective in detecting osseous stress injuries [81]. Overall, MRI is the imaging test that globally evaluates all anatomic structures, including bone marrow [13,82].

Chronic Ankle Pain. CT Arthrography One study involving anterolateral ankle impingement compared CT arthrography to arthroscopic findings. The study found that CT arthrography had a sensitivity and specificity of 97% and 71%, respectively [77]. Image-guided Anesthetic Injection Fluoroscopic or US-guided injections have been shown as an effective treatment for some ankle impingement syndromes [78,79]. Bone Scan with SPECT or SPECT/CT Recently, SPECT combined with CT has been shown to provide additional information compared with clinical diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft-tissue pathology [7]. One study found that SPECT/CT provided information not suspected on clinical diagnosis in 56% of cases with impingement syndromes or soft-tissue pathology [7]. CT CT CT may be useful for depiction of osseous causes of impingement, such as chronic abnormalities between the talus and an os trigonum or fractures of the lateral tubercle of the talus or os trigonum [62]. Arthrography Arthrography is not routinely used for the evaluation of ankle impingement syndromes. Radiography Stress views are not routinely used for the evaluation of ankle impingement syndromes. Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study. When chronic ankle pain is of unclear etiology, normal ankle radiographs can be followed by other imaging tests, primarily directed by clinical findings. Chronic Ankle Pain MRI If the patient has a focal soft-tissue abnormality, MRI can be considered. Peripheral nerve-related symptoms can be evaluated with US or MRI; however, US has the benefit of higher resolution. If symptoms are believed to originate from osseous structures, MRI can be considered if there is concern for an initially missed fracture [80]. MRI is effective in detecting osseous stress injuries [81]. Overall, MRI is the imaging test that globally evaluates all anatomic structures, including bone marrow [13,82].

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acrac_3102398_0

Postmenopausal Acute Pelvic Pain

The literature regarding etiology of acute, rather than chronic, pain in postmenopausal women is somewhat limited. In a single-center study, investigators noted that ovarian cysts account for one-third of the cases of pain attributed to gynecologic origin in perimenopausal and postmenopausal women [3]. This is a slightly less common cause of pain than in the reproductive age group. Uterine fibroids are the are the second most common cause of acute pelvic pain in the peri/postmenopausal group, and a significantly more common cause of pain than in the premenopausal group [3]. Acute pain from fibroids may be secondary to torsion of pedunculated fibroids, prolapse of a submucosal fibroid, or from acute infarction/hemorrhage in a degenerating fibroid. The third most common cause of pelvic pain is pelvic infection, which accounts for 20% of cases [3]. These cases of pelvic inflammatory disease (PID) include tubo-ovarian abscess, oophoritis, salpingitis, endometritis, cervicitis, or peritonitis from gynecologic origin. The majority of these are related to sexual activity; however, recent instrumentation and surgery are common iatrogenic causes. Isolated endometritis can also be seen with cervical stenosis. The fourth most common gynecologic cause of acute pelvic pain is ovarian neoplasm, which is the etiology in 8% of cases [3]. Ovarian torsion, retained intrauterine device, and endometriosis have been reported as causes of acute pain in the postmenopausal period; however, these are considered rare. In the postmenopausal woman, other causes of pelvic pain are attributable to the urinary, gastrointestinal, and vascular systems [4]. Imaging recommendations vary for these etiologies, and narrowing of the differential will help ensure optimal diagnostic imaging. Please see the corresponding ACR Appropriateness Criteria guidance document, which addresses these diagnoses listed in Appendix 1. OR Reprint requests to: publications@acr.org Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. The literature regarding etiology of acute, rather than chronic, pain in postmenopausal women is somewhat limited. In a single-center study, investigators noted that ovarian cysts account for one-third of the cases of pain attributed to gynecologic origin in perimenopausal and postmenopausal women [3]. This is a slightly less common cause of pain than in the reproductive age group. Uterine fibroids are the are the second most common cause of acute pelvic pain in the peri/postmenopausal group, and a significantly more common cause of pain than in the premenopausal group [3]. Acute pain from fibroids may be secondary to torsion of pedunculated fibroids, prolapse of a submucosal fibroid, or from acute infarction/hemorrhage in a degenerating fibroid. The third most common cause of pelvic pain is pelvic infection, which accounts for 20% of cases [3]. These cases of pelvic inflammatory disease (PID) include tubo-ovarian abscess, oophoritis, salpingitis, endometritis, cervicitis, or peritonitis from gynecologic origin. The majority of these are related to sexual activity; however, recent instrumentation and surgery are common iatrogenic causes. Isolated endometritis can also be seen with cervical stenosis. The fourth most common gynecologic cause of acute pelvic pain is ovarian neoplasm, which is the etiology in 8% of cases [3]. Ovarian torsion, retained intrauterine device, and endometriosis have been reported as causes of acute pain in the postmenopausal period; however, these are considered rare. In the postmenopausal woman, other causes of pelvic pain are attributable to the urinary, gastrointestinal, and vascular systems [4]. Imaging recommendations vary for these etiologies, and narrowing of the differential will help ensure optimal diagnostic imaging. Please see the corresponding ACR Appropriateness Criteria guidance document, which addresses these diagnoses listed in Appendix 1. OR Reprint requests to: publications@acr.org Postmenopausal Acute Pelvic Pain

3102398

acrac_3102398_1

Postmenopausal Acute Pelvic Pain

Discussion of Procedures by Variant Variant 1: Postmenopausal acute pelvic pain. Initial imaging. CT Abdomen and Pelvis CT abdomen and pelvis may be useful in the setting of poorly localized pain, masses, or organomegaly involving both the abdomen and pelvis as well as in assessment of abdominal vasculature and ascites. CT is useful in the evaluation of patients with a nonspecific clinical presentation or broad differential diagnosis, including gynecologic and nongynecologic etiologies, and may be a first-line imaging modality in this setting. CT with intravenous (IV) contrast had higher sensitivity than ultrasound (US) (89% versus 70%) for urgent diagnoses in a mixed-gender group of adults with abdominopelvic pain [5], and approximately 88% overall accuracy compared with surgical diagnosis in a similar cohort [6]. Although specific data are lacking for the postmenopausal population, CT is also widely used as a second-line imaging modality in patients with an equivocal or nondiagnostic US evaluation, particularly when there is concern for appendicitis [7,8]. The bulk of evidence to support the use of a CT abdomen and pelvis in acute postmenopausal pelvic pain refers to contrast-enhanced imaging. For gynecologic diagnoses, contrast-enhanced CT may identify ovarian cysts and masses, including solid components, as well as ascites, or lymphadenopathy that may raise suspicion for a malignant diagnosis [9-11]. However, the accuracy of CT for adnexal mass characterization remains limited. CT is distinctly helpful when macroscopic fat or calcifications of teeth or bone fragments are present, to confirm the diagnosis of ovarian teratoma. Regarding ovarian torsion, CT findings have been described but specific diagnostic accuracy has not been reported to our knowledge.

Postmenopausal Acute Pelvic Pain. Discussion of Procedures by Variant Variant 1: Postmenopausal acute pelvic pain. Initial imaging. CT Abdomen and Pelvis CT abdomen and pelvis may be useful in the setting of poorly localized pain, masses, or organomegaly involving both the abdomen and pelvis as well as in assessment of abdominal vasculature and ascites. CT is useful in the evaluation of patients with a nonspecific clinical presentation or broad differential diagnosis, including gynecologic and nongynecologic etiologies, and may be a first-line imaging modality in this setting. CT with intravenous (IV) contrast had higher sensitivity than ultrasound (US) (89% versus 70%) for urgent diagnoses in a mixed-gender group of adults with abdominopelvic pain [5], and approximately 88% overall accuracy compared with surgical diagnosis in a similar cohort [6]. Although specific data are lacking for the postmenopausal population, CT is also widely used as a second-line imaging modality in patients with an equivocal or nondiagnostic US evaluation, particularly when there is concern for appendicitis [7,8]. The bulk of evidence to support the use of a CT abdomen and pelvis in acute postmenopausal pelvic pain refers to contrast-enhanced imaging. For gynecologic diagnoses, contrast-enhanced CT may identify ovarian cysts and masses, including solid components, as well as ascites, or lymphadenopathy that may raise suspicion for a malignant diagnosis [9-11]. However, the accuracy of CT for adnexal mass characterization remains limited. CT is distinctly helpful when macroscopic fat or calcifications of teeth or bone fragments are present, to confirm the diagnosis of ovarian teratoma. Regarding ovarian torsion, CT findings have been described but specific diagnostic accuracy has not been reported to our knowledge.

3102398

acrac_3102398_2

Postmenopausal Acute Pelvic Pain

CT findings of ovarian torsion include an enlarged, featureless, and hypoenhancing ovary, sometimes with apparent swirling of vascular pedicle and abnormal craniocaudal orientation of ovary or uterine deviation to the affected side [12-16]. Contrast-enhanced CT may be helpful for identification of uterine fibroids that have undergone torsion or necrosis [12,17], with the findings of diminished contrast enhancement of the fibroid(s) (86% sensitivity) and ascites (100% sensitivity) demonstrating the best diagnostic performance in a series of 51 cases [18]. CT is also helpful in evaluation of fibroids when calcified masses cause shadowing and limit visualization of the pelvic contents by US [19]. Contrast-enhanced CT may aid in the early diagnosis of PID with the findings of pelvic fluid, loss of normal fat planes, and/or subtle enhancement of the endocervical canal or fallopian tubes prior to emergence of the dilatation and enlargement that can be identified with US [20,21]. Fulminant PID on CT demonstrates fluid in the endometrial canal, distended and thickened fallopian tubes with wall enhancement, and ovarian enlargement [12,20,22]. CT findings late in the course of PID with formation of a tubo-ovarian abscess includes a complex cystic mass with thick enhancing walls [14,22] and anterior displacement of the mesosalpinx, which helps to distinguish tubo-ovarian abscess from other sources of abscess formation in the pelvis [12,22,23]. MRI Pelvis MRI is most often utilized as a problem-solving examination if US or CT do not reveal an etiology of pain. Potential benefits of MRI in the acute pelvic pain setting are high spatial resolution and excellent soft-tissue contrast. This allows for more precise localization and origin of pathology identified on US and CT [12,24].

Postmenopausal Acute Pelvic Pain. CT findings of ovarian torsion include an enlarged, featureless, and hypoenhancing ovary, sometimes with apparent swirling of vascular pedicle and abnormal craniocaudal orientation of ovary or uterine deviation to the affected side [12-16]. Contrast-enhanced CT may be helpful for identification of uterine fibroids that have undergone torsion or necrosis [12,17], with the findings of diminished contrast enhancement of the fibroid(s) (86% sensitivity) and ascites (100% sensitivity) demonstrating the best diagnostic performance in a series of 51 cases [18]. CT is also helpful in evaluation of fibroids when calcified masses cause shadowing and limit visualization of the pelvic contents by US [19]. Contrast-enhanced CT may aid in the early diagnosis of PID with the findings of pelvic fluid, loss of normal fat planes, and/or subtle enhancement of the endocervical canal or fallopian tubes prior to emergence of the dilatation and enlargement that can be identified with US [20,21]. Fulminant PID on CT demonstrates fluid in the endometrial canal, distended and thickened fallopian tubes with wall enhancement, and ovarian enlargement [12,20,22]. CT findings late in the course of PID with formation of a tubo-ovarian abscess includes a complex cystic mass with thick enhancing walls [14,22] and anterior displacement of the mesosalpinx, which helps to distinguish tubo-ovarian abscess from other sources of abscess formation in the pelvis [12,22,23]. MRI Pelvis MRI is most often utilized as a problem-solving examination if US or CT do not reveal an etiology of pain. Potential benefits of MRI in the acute pelvic pain setting are high spatial resolution and excellent soft-tissue contrast. This allows for more precise localization and origin of pathology identified on US and CT [12,24].

3102398

acrac_3102398_3

Postmenopausal Acute Pelvic Pain

Contrast-enhanced MRI provides the greatest soft-tissue detail for evaluation of uterine fibroids and is particularly helpful in evaluating for symptomatic complications including hemorrhage, torsion, infarction, and prolapse [22,31- 33]. MRI is probably not necessary as a primary imaging modality in uncomplicated cases of PID, but it is useful for anatomic specificity and facilitating treatment planning [12,24,34,35]. MRI is reported to be 95% sensitive and 89% specific for evaluation of hydrosalpinx [36]. The majority of the above reports have focused on the utility of contrast-enhanced MRI, but valuable information can often be derived from noncontrast protocols with emphasis on T2-weighted imaging. Abbreviated MRI Postmenopausal Acute Pelvic Pain protocols without IV contrast have demonstrated 73% accuracy for diagnosis of acute pelvic pain in a mixed group of men, pregnant women, and nonpregnant women [29]. US Pelvis Transabdominal US is considered a first-line imaging modality for evaluation of pelvic pain of suspected gynecologic origin [37]. Transabdominal US is most often performed in conjunction with transvaginal US. Transabdominal US has the benefit of a larger field of view that allows visualization of the uterus and adnexa, but also the remainder of the pelvic contents, including free pelvic fluid. Transabdominal US is well tolerated by patients; however, it can be limited by patient body habitus. The evidence presented below for transvaginal US generally assumes a combined approach using both techniques. US Pelvis Transvaginal Transvaginal US is considered a first-line imaging modality for evaluation of pelvic pain of suspected gynecologic origin and, although it may be performed independently, is usually performed at the same time as a transabdominal US per the ACR-ACOG-AIUM-SPR-SRU Practice Parameter for the Performance of Ultrasound of the Female Pelvis [37].

Postmenopausal Acute Pelvic Pain. Contrast-enhanced MRI provides the greatest soft-tissue detail for evaluation of uterine fibroids and is particularly helpful in evaluating for symptomatic complications including hemorrhage, torsion, infarction, and prolapse [22,31- 33]. MRI is probably not necessary as a primary imaging modality in uncomplicated cases of PID, but it is useful for anatomic specificity and facilitating treatment planning [12,24,34,35]. MRI is reported to be 95% sensitive and 89% specific for evaluation of hydrosalpinx [36]. The majority of the above reports have focused on the utility of contrast-enhanced MRI, but valuable information can often be derived from noncontrast protocols with emphasis on T2-weighted imaging. Abbreviated MRI Postmenopausal Acute Pelvic Pain protocols without IV contrast have demonstrated 73% accuracy for diagnosis of acute pelvic pain in a mixed group of men, pregnant women, and nonpregnant women [29]. US Pelvis Transabdominal US is considered a first-line imaging modality for evaluation of pelvic pain of suspected gynecologic origin [37]. Transabdominal US is most often performed in conjunction with transvaginal US. Transabdominal US has the benefit of a larger field of view that allows visualization of the uterus and adnexa, but also the remainder of the pelvic contents, including free pelvic fluid. Transabdominal US is well tolerated by patients; however, it can be limited by patient body habitus. The evidence presented below for transvaginal US generally assumes a combined approach using both techniques. US Pelvis Transvaginal Transvaginal US is considered a first-line imaging modality for evaluation of pelvic pain of suspected gynecologic origin and, although it may be performed independently, is usually performed at the same time as a transabdominal US per the ACR-ACOG-AIUM-SPR-SRU Practice Parameter for the Performance of Ultrasound of the Female Pelvis [37].

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Orbital Imaging and Vision Loss Child

Introduction/Background Orbital disorders in children consist of varied pathologies affecting orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. Clinical manifestations of these disorders may range from ophthalmoplegia, decreased visual acuity, diplopia, nystagmus, exophthalmos/enophthalmos, papilledema, orbital soft tissue swelling, orbital pain, and, in most severe cases, monocular or binocular vision loss. The underlying etiology of these disorders may be traumatic or nontraumatic. Detailed clinical history along with a thorough clinical examination, including ophthalmologic and neurologic examination, is frequently able to localize the abnormality along the visual pathway. Presumed location of the lesion along with the additional findings like eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, and so on, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and /or head) [1]. Occasionally clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play key role in depicting the nature and extent of the injury or disease [2]. Localization of the orbital abnormality on imaging is facilitated by a compartmental approach, which helps in the differential diagnosis based on the lesion location within the orbit (globe, extraconal, or intraconal space) or elsewhere in the visual pathway [3]. Traumatic injury in the setting of head injury or nonaccidental injury is discussed separately in ACR Appropriateness Criteria on these topics and is therefore excluded from this review. Special Imaging Considerations Ultrasound (US) is also an important diagnostic tool but is most often performed by the ophthalmologist or emergency physician and therefore not covered in this article.

Orbital Imaging and Vision Loss Child. Introduction/Background Orbital disorders in children consist of varied pathologies affecting orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. Clinical manifestations of these disorders may range from ophthalmoplegia, decreased visual acuity, diplopia, nystagmus, exophthalmos/enophthalmos, papilledema, orbital soft tissue swelling, orbital pain, and, in most severe cases, monocular or binocular vision loss. The underlying etiology of these disorders may be traumatic or nontraumatic. Detailed clinical history along with a thorough clinical examination, including ophthalmologic and neurologic examination, is frequently able to localize the abnormality along the visual pathway. Presumed location of the lesion along with the additional findings like eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, and so on, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and /or head) [1]. Occasionally clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play key role in depicting the nature and extent of the injury or disease [2]. Localization of the orbital abnormality on imaging is facilitated by a compartmental approach, which helps in the differential diagnosis based on the lesion location within the orbit (globe, extraconal, or intraconal space) or elsewhere in the visual pathway [3]. Traumatic injury in the setting of head injury or nonaccidental injury is discussed separately in ACR Appropriateness Criteria on these topics and is therefore excluded from this review. Special Imaging Considerations Ultrasound (US) is also an important diagnostic tool but is most often performed by the ophthalmologist or emergency physician and therefore not covered in this article.

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Orbital Imaging and Vision Loss Child

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: publications@acr.org Orbital Imaging and Vision Loss-Child Discussion of Procedures by Variant Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging. Traumatic injury is the leading cause of noncongenital monocular vision loss in children [4]. Common signs of orbital injuries include periorbital soft tissue swelling, ecchymosis, hyphemia, subconjunctival hemorrhage, diplopia, restriction of ocular movement, or vision loss. The most common causes of pediatric orbital fractures are motor vehicle collision, sports injury, falls, and assault [5]. Data from combined pediatric and adult series show that ocular injuries account for approximately 3% of all visits to the emergency department [6]. Orbital fractures account for 3% to 45% of all pediatric facial fractures [5]. Orbital roof fractures are the most common orbital fractures in children <8 years of age, and orbital floor fractures are most common in older children [7]. Serious ocular injuries in conjunction with orbital fracture are less common in children compared with adults. In one series, serious ocular injury was reported in approximately 20% of children with orbital fractures [7]. Traumatic brain injuries are more commonly associated with orbital fractures in younger children because orbital roof fractures are more common in this age group [7]. Elastic, cancellous bone with resilient periosteum in children leads to trap door orbital fracture, which in turn causes entrapment of the extraocular muscles or other orbital contents [8], leading to restriction of ocular movement and diplopia.

Orbital Imaging and Vision Loss Child. 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: publications@acr.org Orbital Imaging and Vision Loss-Child Discussion of Procedures by Variant Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging. Traumatic injury is the leading cause of noncongenital monocular vision loss in children [4]. Common signs of orbital injuries include periorbital soft tissue swelling, ecchymosis, hyphemia, subconjunctival hemorrhage, diplopia, restriction of ocular movement, or vision loss. The most common causes of pediatric orbital fractures are motor vehicle collision, sports injury, falls, and assault [5]. Data from combined pediatric and adult series show that ocular injuries account for approximately 3% of all visits to the emergency department [6]. Orbital fractures account for 3% to 45% of all pediatric facial fractures [5]. Orbital roof fractures are the most common orbital fractures in children <8 years of age, and orbital floor fractures are most common in older children [7]. Serious ocular injuries in conjunction with orbital fracture are less common in children compared with adults. In one series, serious ocular injury was reported in approximately 20% of children with orbital fractures [7]. Traumatic brain injuries are more commonly associated with orbital fractures in younger children because orbital roof fractures are more common in this age group [7]. Elastic, cancellous bone with resilient periosteum in children leads to trap door orbital fracture, which in turn causes entrapment of the extraocular muscles or other orbital contents [8], leading to restriction of ocular movement and diplopia.

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Orbital Imaging and Vision Loss Child

Incarceration of the inferior rectus muscle within a trap door fracture may rapidly result in ischemic injury of the muscle and subsequent restrictive strabismus. However, diplopia itself does not imply extraocular muscle entrapment as soft tissue swelling, hematoma, or nerve paresis can also lead to restricted ocular movement [9]. The presence of visual loss or visual field defects suggests direct or indirect injury to the globe or optic nerve. Open globe injury may be a result of blunt trauma (globe rupture) or penetrating injury (globe laceration). Penetrating injuries may also be associated with intraorbital foreign body. Imaging may be conducted to assess for the intraorbital foreign body, extent of globe damage, and injury to the surrounding structures [10,11]. CT Head CT of the head may have a complementary role when obtained along with CT orbits in cases in which intracranial abnormality or calvarial fracture is suspected, particularly in children with suspected orbital roof fracture. Outside the setting of concurrent head trauma, there is no relevant literature to support the role for CT head in the initial evaluation of the orbital trauma. CT Orbits CT is considered the most useful imaging modality in evaluating orbital trauma, and it is the most accurate method in detecting fractures [12]. CT may also provide information for the detection of soft tissue injuries (including globe or extraocular muscles), hemorrhage, and presence of an intraocular foreign body. CT was found to be 94.9% sensitive for detection of the intraorbital foreign body, especially metallic or glass foreign bodies [13]. There is no relevant literature to support the role for contrast-enhanced CT orbits in the initial evaluation of the orbital trauma. CTA Head There is no relevant literature to support the use of CT angiography (CTA) head in the initial evaluation of orbital trauma.

Orbital Imaging and Vision Loss Child. Incarceration of the inferior rectus muscle within a trap door fracture may rapidly result in ischemic injury of the muscle and subsequent restrictive strabismus. However, diplopia itself does not imply extraocular muscle entrapment as soft tissue swelling, hematoma, or nerve paresis can also lead to restricted ocular movement [9]. The presence of visual loss or visual field defects suggests direct or indirect injury to the globe or optic nerve. Open globe injury may be a result of blunt trauma (globe rupture) or penetrating injury (globe laceration). Penetrating injuries may also be associated with intraorbital foreign body. Imaging may be conducted to assess for the intraorbital foreign body, extent of globe damage, and injury to the surrounding structures [10,11]. CT Head CT of the head may have a complementary role when obtained along with CT orbits in cases in which intracranial abnormality or calvarial fracture is suspected, particularly in children with suspected orbital roof fracture. Outside the setting of concurrent head trauma, there is no relevant literature to support the role for CT head in the initial evaluation of the orbital trauma. CT Orbits CT is considered the most useful imaging modality in evaluating orbital trauma, and it is the most accurate method in detecting fractures [12]. CT may also provide information for the detection of soft tissue injuries (including globe or extraocular muscles), hemorrhage, and presence of an intraocular foreign body. CT was found to be 94.9% sensitive for detection of the intraorbital foreign body, especially metallic or glass foreign bodies [13]. There is no relevant literature to support the role for contrast-enhanced CT orbits in the initial evaluation of the orbital trauma. CTA Head There is no relevant literature to support the use of CT angiography (CTA) head in the initial evaluation of orbital trauma.

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Orbital Imaging and Vision Loss Child

MRA Head There is no relevant literature to support the use of MR angiography (MRA) head in the initial evaluation of orbital trauma. MRI Head MRI of the head provides more detailed information about brain parenchyma and other intracranial structures due to its superior soft tissue contrast (versus CT) but remains supplementary to a CT as an initial imaging modality in the setting of orbital trauma. There is no relevant literature to support the role of contrast-enhanced MRI head in the initial evaluation of the orbital trauma. MRI Orbits MRI of the orbits may provide useful detailed information due to its superior soft tissue contrast, particularly in the evaluation of the globe and optic nerves. MRI may also be useful in detecting nonmetallic intraorbital foreign body, especially a wooden foreign body, which may appear hypoattenuating on CT and may be mistaken for air [12]. However, it remains supplementary to a CT scan as an initial imaging modality in orbital trauma. There is no relevant literature to support the role of contrast-enhanced MRI orbits in the initial evaluation of orbital trauma. Orbital Imaging and Vision Loss-Child Radiography Orbit Radiography is insufficient in the detection of the pathology in cases of orbital trauma and has been replaced by CT in current clinical practice [12]. Radiography of the orbits may have a role as a screening modality for the detection of a metallic intraorbital foreign body before performing an MRI scan. However, a CT scan of the orbits is a more sensitive modality for detection of metallic intraocular foreign body and is usually performed prior to MRI in cases of orbital trauma [12,13]. Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging. Causes of acute nontraumatic vision loss in children may be due to ocular abnormalities or lesions in the neurovisual pathway. Ocular abnormalities involving the cornea, lens, or anterior chamber are best diagnosed by an ophthalmologic examination.

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MR angiography (MRA) head in the initial evaluation of orbital trauma. MRI Head MRI of the head provides more detailed information about brain parenchyma and other intracranial structures due to its superior soft tissue contrast (versus CT) but remains supplementary to a CT as an initial imaging modality in the setting of orbital trauma. There is no relevant literature to support the role of contrast-enhanced MRI head in the initial evaluation of the orbital trauma. MRI Orbits MRI of the orbits may provide useful detailed information due to its superior soft tissue contrast, particularly in the evaluation of the globe and optic nerves. MRI may also be useful in detecting nonmetallic intraorbital foreign body, especially a wooden foreign body, which may appear hypoattenuating on CT and may be mistaken for air [12]. However, it remains supplementary to a CT scan as an initial imaging modality in orbital trauma. There is no relevant literature to support the role of contrast-enhanced MRI orbits in the initial evaluation of orbital trauma. Orbital Imaging and Vision Loss-Child Radiography Orbit Radiography is insufficient in the detection of the pathology in cases of orbital trauma and has been replaced by CT in current clinical practice [12]. Radiography of the orbits may have a role as a screening modality for the detection of a metallic intraorbital foreign body before performing an MRI scan. However, a CT scan of the orbits is a more sensitive modality for detection of metallic intraocular foreign body and is usually performed prior to MRI in cases of orbital trauma [12,13]. Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging. Causes of acute nontraumatic vision loss in children may be due to ocular abnormalities or lesions in the neurovisual pathway. Ocular abnormalities involving the cornea, lens, or anterior chamber are best diagnosed by an ophthalmologic examination.

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Orbital Imaging and Vision Loss Child

Various abnormalities of the neurovisual pathway (including optic nerve, optic chiasm, optic tracts, thalamus, optic radiations, or visual cortex) that may present with acute visual loss or defect are covered in this variant. These may include optic neuritis, which may be secondary to demyelinating disorders (multiple sclerosis, neuromyelitis optica spectrum disorders), other inflammatory, infectious, or granulomatous disorders, or unknown underlying cause (idiopathic). This variant also includes lesions involving the brain parenchyma in the region of thalamus, optic radiations, or occipital lobes, which may have acute presentation (eg, infarct, hemorrhage, inflammatory, infectious, or demyelination processes). Ocular migraine is a common cause of transient acute monocular vision loss with ipsilateral headache in adolescents. It is diagnosed based on the clinical history and examination. Imaging is performed to exclude other causes of vision loss and headache [14]. Lastly, nonorganic (psychogenic) acute vision loss is not uncommon in school age children. These are diagnosed by exclusion, based on the clinical history, inconsistent clinical examination, and negative imaging studies [15,16]. CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children with nontraumatic vision loss. CT Head CT of the head without intravenous (IV) contrast may be complementary to MRI head for a suspected brain lesion, especially if infarct or hemorrhage in the neurovisual pathway is suspected. There is no relevant literature to support the role for contrast-enhanced CT head in the initial evaluation of children with nontraumatic vision loss. CT Orbits There is no relevant literature to support the use of CT orbits in the initial evaluation of children with nontraumatic vision loss.

Orbital Imaging and Vision Loss Child. Various abnormalities of the neurovisual pathway (including optic nerve, optic chiasm, optic tracts, thalamus, optic radiations, or visual cortex) that may present with acute visual loss or defect are covered in this variant. These may include optic neuritis, which may be secondary to demyelinating disorders (multiple sclerosis, neuromyelitis optica spectrum disorders), other inflammatory, infectious, or granulomatous disorders, or unknown underlying cause (idiopathic). This variant also includes lesions involving the brain parenchyma in the region of thalamus, optic radiations, or occipital lobes, which may have acute presentation (eg, infarct, hemorrhage, inflammatory, infectious, or demyelination processes). Ocular migraine is a common cause of transient acute monocular vision loss with ipsilateral headache in adolescents. It is diagnosed based on the clinical history and examination. Imaging is performed to exclude other causes of vision loss and headache [14]. Lastly, nonorganic (psychogenic) acute vision loss is not uncommon in school age children. These are diagnosed by exclusion, based on the clinical history, inconsistent clinical examination, and negative imaging studies [15,16]. CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children with nontraumatic vision loss. CT Head CT of the head without intravenous (IV) contrast may be complementary to MRI head for a suspected brain lesion, especially if infarct or hemorrhage in the neurovisual pathway is suspected. There is no relevant literature to support the role for contrast-enhanced CT head in the initial evaluation of children with nontraumatic vision loss. CT Orbits There is no relevant literature to support the use of CT orbits in the initial evaluation of children with nontraumatic vision loss.

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