Neuroradiology Update 2015
Thomas B. Sanders, MD Neuroradiologist, Utah Radiology Associates; Provo, Utah
Objectives:
• Review MRI L-spine appropriateness pilot project • Discuss the role of headache imaging • Review headache imaging indications project • List future projects
IHCNeuroradiologyUpdate2015
Thomas Sanders MDIHC Neuroradiology Section LeadUtah Radiology Associates Neuroradiology
OBJECTIVES
•Review MRI L‐spine appropriateness pilot project
•Discuss the role of headache imaging•Review headache imaging indications project
•Highlight future projects
AppropriatenessPilotObjective:
• Assess % of MRI‐L spine exams that meet appropriateness guidelines.
• Assess how efficiently a working radiologist can clearly determine appropriateness of a MRI L‐spine exam.
AppropriatenessPilotDescription:
• Retrospectively reviewed USR MR L‐Spine exams (600 Cases)
• Reviewed documentation currently available in RW (USR Patient Screening Form, RIS History, Order, Tech Notes, ED Notes)
• Appropriateness Criteria utilized: ACR and ACP guidelines
• Two Reviewers: TS and DC
ACR AppropriatenessCriteria
Recent Significant Trauma Unexplained Weight loss Unexplained Fever (history of infection) Immunosuppressed (Diabetes Mellitus) Cancer History IV Drug Use Prolonged Corticosteroid/ Age >50 with Osteoporosis Age >70 Focal Deficit with Progressive or Disabling Symptoms,
Cauda Equina Duration > 6 weeks Prior Surgery
AppropriatenessPilotPrimary Findings:
• 97% of exams had adequate info for assessment
• Minimal additional time to assess appropriateness
• 87% of exams were deemed appropriate
• 10% of exams were deemed inappropriate
• 3% of exams were indeterminate
AppropriatenessPilotAdditional Findings:
• Surgical patients • Repeat exams• Tech training to ensure key questions on the patient survey are completed (length of symptoms/progressive nature)
• Inpatient/ED patients would benefit from utilizing outpatient screening form
HEADACHEIMAGING
HEADACHEIMAGING
• Headache is a frequent patient presentation
• Most often the patient’s headache cause or type can be determined with a careful history & physical
• Headache Imaging has a low yield • Non‐traumatic HA yield ~0.4%
• Estimated cost to detect a lesion• $100,000 with CT• $225,000 with MR
HEADACHEIMAGING
• Positive predictive value for intracranial pathology if the neurologic exam is abnormal = 39%
• A normal neurologic exam reduced the odds of a positive finding on neuroimaging by 30%
HEADACHEIMAGING
• Neuroimaging ordered in ~12% of US outpatient headache visits
• Headache Imaging cost ~1 billion annually
• Studies document increased HA imaging utilization despite imaging guidelines
• What is the True Value of a Negative Imaging Study??? (Not Zero)
• Imaging guidelines should be focused on defining patients with treatable lesions
HeadacheImagingIndicationsWorkGroup
• Multispecialty: Neurology, Internal Medicine, Emergency Medicine, Radiology
• Review established guidelines
• Formulate local best practice standard
HeadacheImagingIndicationsWorkGroup
• Adult• Non‐traumatic Acute• Non‐traumatic chronic• Mild TBI
References
FutureProjects
• Tele‐stroke (Neuro‐Science Clinical Program)
• Service Process Models• Standardized Templates• Standardized Protocols• Educational Modules• Appropriateness Work‐groups