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Your Image Our Vision
Your Choice
Introduction
This guide is meant to assist physicians when ordering imaging exams based on
common clinical situations. The goal is to assist physicians with ordering the most
optimal imaging study for their patients. We hope these guidelines will be useful in
most clinical situations and beneficial for both the physician and patient.
However, we know situations will arise that require a one on one consultation with a
Radiologist. As needed, please feel free to consult our team of sub-specialty
Radiologists. This will allow us to partner with you and determine the best approach for
your particular patient. The contact information for each sub-specialty team is listed
for your convenience.
VRI PACS – Image/Report Portal
Referring offices have the ability to access patient images and view reports online via
our PACS Portal. If you need assistance with getting this set up for your practice, then
please contact: Kellie Markovich – Marketing & Business Development Coordinator
(910) 323-2209 / [email protected]
You can access our PACS Portal at: www.valleyregionalimaging.com
If you experience IT related issues, then please contact Xodus Technology Professionals
for assistance/support: Ted Best – Systems Engineer-Health IT|Radiology
(888) 607-2414 Ext. 7000 / www.xodus-is.com
VRI RIS - Scheduling Portal
Referring offices have the ability to submit imaging orders online via our Scheduling
Portal. Using the portal, you can schedule appointments directly, follow-up on
scheduled and completed appointments, and pull patients reports. If you need
assistance with getting this set up for your practice, then please contact:
Kellie Markovich – Marketing & Business Development Coordinator
(910) 323-2209 / [email protected]
3
You can access our RIS Scheduling Portal at: www.valleyregionalimaging.com
If you experience IT related issues, then please contact Xodus Technology Professionals
for assistance/support: Ted Best – Systems Engineer-Health IT|Radiology
(888) 607-2414 Ext. 7000 / www.xodus-is.com
Table of Contents
I.
Special Considerations
II.
Breast Imaging
III. Chest Imaging
IV. Endocrine Disorders
V. Gastrointestinal Imaging
VI. Genitourinary System
VII. Interventional Radiology
VIII. Musculoskeletal Imaging
IX. Neurologic Imaging
X.
Pediatric Imaging
XI. Appendices
Locations and Services Offered
Affiliated Hospitals
CRR Radiologists
4
for assistance/support: Ted Best – Systems Engineer-Health IT|Radiology
(888) 607-2414 Ext. 7000 / www.xodus-is.com
Table of Contents
I.
Special Considerations
II.
Breast Imaging
III. Chest Imaging
IV. Endocrine Disorders
V. Gastrointestinal Imaging
VI. Genitourinary System
VII. Interventional Radiology
VIII. Musculoskeletal Imaging
IX. Neurologic Imaging
X.
Pediatric Imaging
XI. Appendices
Locations and Services Offered
Affiliated Hospitals
CRR Radiologists
4
Special Considerations
Decreased Renal Function and Need for Contrast-Enhanced CT:
e-GFR < 30 or serum creatinine of > 2: No IV contrast.
e-GFR 30 - 60: Reduced dose of contrast and Visipaque 320.
IV and oral hydration to reduce risk of contrast induced
nephropathy.
Risk Factors for Contrast–Induced Nephropathy:
Baseline decreased renal function (creatinine > 1.5mg/dL)
Dehydration
Elderly
Hypertensive nephropathy
Diabetic nephropathy
Multiple myeloma
Repeat administration of contrast over short period of time
Ionic high-osmolar contrast agents
Nephrotoxic medications
Patients with history of mild or moderate allergic reaction to
iodinated IV contrast used in CT should be pre-medicated.
50mg of Prednisone PO 13 hours, 7 hours, and 1 hour before
the IV contrast administration; plus,
50mg of Benadryl PO 1 hour before the IV contrast
administration; plus,
50mg of Prednisone PO 6 hours after IV contrast
administration.
MRI should be considered for patients with prior severe allergic
reaction to iodinated contrast based on the need of a contrastenhanced cross-sectional exam.
5
Decreased Renal Function and Need for Contrast-Enhanced MRI:
eGFR < 30: No IV Gadolinium-based IV contrast unless
absolutely essential.
e-GFR 30 - 60: Gadolinium-based IV contrast dose of
0.1 mmol/kg or less.
e-GFR > 60: Gadolinium-based IV contrast can be administered
safely.
[Please note: Dialysis patients are at a much higher risk for Gadoliniumbased IV contrast agent induced Nephrogenic Systemic Fibrosis (NSF)].
For Patients Unable to Follow Commands/Breathing Instructions:
CT is less sensitive to motion than MRI.
Pregnancy and Appendicitis:
First and second trimester: U/S of the Right Lower Quadrant
(RLQ) followed by MRI without contrast if U/S is non-diagnostic
or equivocal.
Third trimester: MRI without contrast.
CT Abdomen and Pelvis with IV and oral contrast if MRI is
unavailable.
Pregnancy and Trauma:
Initial work-up with Chest X-Ray, lateral X-Ray of the Cervical
Spine, and U/S examination of the gravid uterus and abdomen
(focused abdominal sonogram for trama-FAST).
CT for hemodynamically stable seriously injured pregnant
patient with blunt trauma.
Pregnancy and Urolithiasis:
U/S is recommended.
Unenhanced CT if U/S is non-diagnostic.
6
Pregnancy and Pulmonary Embolism (PE) Imaging:
Diagnostic Algorithm for Suspected PE in Pregnancy
Suspected PE in Pregnancy
Present
CUS
Leg Symptoms
Absent
CXR
Negative
Abnormal
Positive
Normal
CTPA
Nondiagnostic
V/Q
TREAT
Negative
Stop
Technically Inadequate Positive
CUS, CTPA
TREAT
Positive
Negative
Stop
Diagnostic Algorithm flow chart delineated above provided by:
http://radiology.rsna.org/content/262/2/635/F1.large.jpg
CUS- Compression Ultrasound of the Lower Extremities.
CTPA-CT Angiogram of the Pulmonary Arteries.
Radiation dose reduction technique after the V/Q scan is
hydration with frequent voiding to reduce fetal exposure form
the urinary bladder.
7
Breast Imaging
Breast Cancer Screening – Asymptomatic Women:
Annual Mammography beginning at age 40.
Breast Cancer Screening – High Risk Women:
Risks include BRCA mutation, personal history of high-risk breast
biopsy, or personal history of thoracic radiation age 10-30 years old.
Annual Mammography beginning at age 40.
Annual Breast MR (for patients with greater than 20% lifetime risk).
Diagnostic Workup – Palpable Mass, Axillary Mass, Bloody Nipple Discharge, Skin Dimpling, or Nipple Retraction:
Diagnostic Mammography.
Breast Ultrasound.
Breast MR – Indications:
High risk screening.
Local staging and contralateral screening in newly diagnosed breast cancer.
Occult breast cancer in positive biopsy axillary lymph nodes or metastases, but
negative mammograms.
Implant rupture.
Assessing response to neoadjuvant therapy.
Problem solving.
High Risk Screening Breast MR – American Cancer Society Recommends:
BRCA mutation.
First degree relative of BRCA mutation, but untested.
Lifetime risk of 20-25% or greater.
Radiation to the chest between age 10-30 years old.
Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome.
First degree relatives.
8
Chest Imaging
1.
Solitary Pulmonary Nodule:
 CT - Fleischner Society Recommendations
Nodule Size
(mm)
Low-Risk Patient
High-Risk Patient
<4
No follow-up needed. Follow up CT at 12 months;
if unchanged, no further
follow up.
>4-6
Follow up CT at 12
Initial follow up CT at 6-12
months; if unchanged, mo then 18-24 months if
no further follow-up.
no change.
>6-8
Initial follow up CT at 6 Initial follow-up CT at 3 - 6
- 12 months; then 18 - months; then at 9 - 12 and
24 months if no change. 24 months if no change.
>8
Follow-up CT at around Follow-up CT at around 3,
3, 9 and 24 months; 9 and 24 months; dynamic
contrast-enhanced CT, PET,
dynamic contrastand/or biopsy.
enhanced CT, PET,
and/or biopsy.
 Consider PET-CT Scan if 1cm or larger nodule.
9
2.
Aortic Aneurysm:
U/S for smaller sized or thin patients for detection.
CT or MRI for larger or obese patients and for follow-up.
3.
Aortic Dissection:
CT Angiogram (CTA with and without Contrast) is used only for
ACUTE dissection. Every effort should be made to reduce
exposure to imaging radiation.
MRI is used for surveillance imaging required for chronic
dissection.
MRI is also preferred for chronic dissection cases that have
undergone surgical repair.
4.
Interstitial Lung Disease:
High-Resolution Chest CT protocol should be used.
5.
Mediastinal Mass:
CT chest with contrast should be the first study ordered for
patients with an abnormal Chest X-Ray or clinical suspicion for
mediastinal mass (other than substernal thyroid).
MRI is best for problem solving.
PET-CT Scan should be used for staging of lung cancer or
malignant adenopathy.
6.
Pleural Effusion:
Chest X-Ray is best for detection or follow-up.
CT with contrast can be used to characterize pleural effusion
and underlying disease process.
10
7.
Pulmonary Embolism:
Chest X-Ray is performed to exclude other causes of
symptoms. This assists in interpretation of Ventilation
Perfusion Lung Scan (V/Q Scan).
CT Angiogram of the pulmonary arteries (CTPA for PE).
 Current weight limit for Valley Regional Imaging (VRI)
CT is 400 lbs.
 Current weight limit for Cape Fear Valley CT is 480 lbs.
Patient can be on ventilator.
Ventilation Perfusion Lung Scan (V/Q Scan) if patient has
history of severe contrast reaction or renal insufficiency.
Please refer to the Special Considerations section for
additional guidelines regarding evaluation for suspected PE in
pregnant patients.
GU | Chest
11
Endocrine Disorders
1.
Adrenal:
Adenoma
 Clinical and laboratory work-up.
 CT Abdomen with adrenal mass protocol (without and with
contrast) or MRI Abdomen without contrast.
Incidentaloma
 Asymptomatic adrenal mass.
 CT Abdomen with adrenal mass protocol (without and with
contrast) or MRI Abdomen without contrast.
Pheochromocytoma
 Thorough clinical work-up.
 First imaging study: CT Abdomen/Pelvis and possibly Chest
CT without contrast.
 MRI to further characterize abnormalities.
 Nuclear Medicine Neuroendocrine study (I-MIBG) for
extraadrenal sites and metastatic disease.
2.
Parathyroid Tumor:
Tc 99m Sestamibi scan is exam of choice.
3.
Thyroid:
Solitary Palpable Mass - Euthyroid Patient
 U/S recommended for confirmation of origin and
characterization (cystic or solid).
 Biopsy depending on size and appearance.
Multinodular Gland on Physical Examination
 U/S recommended.
12
 Biopsy if needed.
Toxic Multinodular Goiter - Clinical Hyperthyroid
 131-I Thyroid Scan and Uptake.
 Treat with I-131.
Graves’ Disease - Clinical Hyperthyroid (Increased TSH)
 131-I Thyroid Scan and Uptake.
 Treat with I-131.
Evaluation for Metastasis - Patient with Thyroid CA
 I-131 Whole Body Scan.
 Treat with high doses of I-131.
PET-CT or CT as indicated
13
Gastrointestinal Imaging
1.
Acute Cholecystitis:
U/S is recommended as the initial study.
HIDA Scan: If diagnosis is equivocal, this should be performed
to establish patency of cystic duct.
If clinical symptoms warrant further investigation after
negative U/S and/or HIDA, consider MRI.
If common duct stones are suspected, consider MRCP.
2.
Acute GI Bleeding:
If endoscopy or NG tube aspirate is negative, then order radiolabled RBC scan
 If RBC scan is positive, consider visceral angiography.
 If RBC scan is negative, consider clinical monitoring
since angiography will also be negative.
3.
Appendicitis:
U/S in infants, children, and pregnant or thin childbearing-age
women is recommended as the initial study.
Consider MRI if the U/S is non-diagnostic with strong clinical
concern in children.
If pregnant, refer to special considerations section.
If not pregnant, use CT Abdomen and Pelvis with oral and IV
contrast.
4.
Bile Leak (Post Operative or Trauma):
HIDA Scan.
If T-Tube is present, then obtain T-Tube Cholangiogram.
MRI/MRCP in selected cases. Typically, it is more accurate for
chronic rather than acute bile leaks.
14
5.
Biliary Obstruction (Jaundice):
U/S is recommended as the initial study.
If U/S shows dilated duct, use MRI/MRCP or CT without and
with contrast (pancreatic mass protocol) to differentiate
between common duct stone and pancreatic head tumor.
HIDA Scan may play role in functional evaluation of benign
appearing dilated duct.
6.
Blunt Abdominal Trauma:
In hemodynamically stable patient, CT Abdomen and Pelvis
with IV contrast is recommended as the initial study.
7.
Chronic Cholecystitis:
U/S is recommended as the initial study.
HIDA Scan with Gallbladder Ejection Fraction for gallbladder
dysfunction as cause of abdominal pain.
8.
Chronic GI Bleeding:
Upper/Lower Endoscopy is recommended as the initial study.
Consider CT Enterography (CTE).
If all studies are negative, then Angiography may find
angiodysplasia.
Meckel’s Scan may be useful in children with lower GI
bleeding.
9.
Dysphagia:
Esophagram (Barium Swallow) is recommended as the initial
study.
Suspicious findings should be followed by endoscopy.
If swallowing dysfunction/aspiration is suspected, request
Speech Pathology Swallowing Evaluation and they will
recommend Modified Barium Swallow if needed.
15
10. Focal Liver Lesions:
MRI Abdomen without and with contrast is the preferred study.
CT Abdomen without and with contrast is a lower cost
alternative, but less desirable in terms of ionizing radiation.
CT should be used for patients with MRI contraindications.
11. Gallstones or Bile Duct Stones (Choledocholithiasis):
U/S is recommended as the initial study.
If gallstones are very small on U/S, consider preoperative
MRI/MRCP, as risk of common bile duct stones is greater with
small gallstones.
12. Hepatosplenomegaly:
U/S is recommended as the initial study.
If volumetric estimation and monitoring is needed, MRI is
preferred.
13. Inflammatory Bowel Disease:
CT Enterography (CTE) is the primary modality for confirmation
of a new diagnosis of Crohn’s Disease.
Routine CT Abdomen and Pelvis is preferred for recurrent
disease, but be mindful of cumulative radiation dose.
14. Pancreatic Mass:
CT Abdomen without and with contrast using pancreatic mass
protocol is the first choice for evaluation of a pancreatic mass.
MRI Abdomen without and with contrast can be more
informative for characterization of pancreatic lesions.
15. Small Bowel Obstruction (SBO):
Acute abdominal series is recommended as the initial study.
16
If non-diagnostic, routine CT Abdomen and Pelvis with Oral and
IV contrast may be definitive and can direct surgical planning.
17
Genitourinary System
1.
Adnexal Mass:
U/S is recommended as the initial study.
Pelvic MRI for characterization if further imaging is required.
2.
Dysfunctional Uterine Bleeding:
U/S is recommended as the initial study.
Pelvic MRI should be performed for more detailed visualization
if uterine artery embolization or other interventions are
planned.
3.
Ectopic Pregnancy:
U/S is recommended.
4.
Obstructive Uropathy:
A KUB X-Ray for stones is recommended as the initial study.
CT Abdomen and Pelvis without IV or oral contrast using renal
stone protocol.
For recurrent obstruction after initial CT, use follow-up KUB
plain films and U/S.
Patients with chronic stone disease and recurrent obstructive
uropathy are best managed with the judicious application of
CT, U/S, KUB plain films, and occasionally MRI. Be mindful of
cumulative radiation dose.
To evaluate presence and degree of obstruction, use
Radionuclide Renogram with Lasix (MAG 3 Lasix Renogram).
Intravenous Pyelogram (IVP) can be performed, but it has a
higher radiation dose.
5.
Painless Hematuria:
A KUB plain film for stones is recommended as the initial study.
18
CT Urogram (CT Abdomen and Pelvis without and with
Contrast) for suspected urothelial neoplasm or follow up for
recurrent/metachronous urothelial neoplasm.
MR Urogram can be used in select patients with history of
severe iodinated contrast reaction.
6.
Penile Mass:
MRI is the preferred modality.
7.
Prostate Cancer:
MRI is used for local and regional staging.
Bone Scan for bone metastases.
8.
Renal Mass:
U/S is recommended to determine cystic vs. solid in thin
patients.
Indeterminate lesions seen on U/S or single phase CT can be
characterized as solid or cystic using CT abdomen with renal
mass protocol (without and with contrast) or MRI without and
with contrast.
9.
Renal Failure:
U/S can be used to assess renal size, echotexture, cortical
thickness, and hydronephrosis.
If hydronephrosis is seen on U/S, then non-contrast CT can help
determine the cause.
10. Suspected Renovascular Disease:
MR Angiography should be considered first. It has high
sensitivity and specificity, and used no radiation; however,
contrast is used and it is slower (more need for sedation). Also,
it is most expensive.
19
CT Angiography would be the second choice. It has high
sensitivity and specificity, and it is less expensive then MRI. It is
also much faster (less need for sedation); however, contrast is
used and the radiation exposure must be considered.
Captopril Renogram is the third alternative. No IV contrast is
required; however, it has lower sensitivity and specificity, it is
slower, somewhat expensive, and also exposes the patient to
radiation.
11. Scrotal Imaging:
U/S is recommended.
20
Interventional Radiology
1.
Compression Fractures:
MRI before treatment to evaluate for edema in acute or
subacute fractures is recommended.
With Vertebroplasty, methyl methacrylate (aka cement) is
injected directly into a fractured vertebral body, resulting in
pain relief by stabilizing the fracture.
With Balloon Kyphoplasty, a balloon is utilized to create a void
for the cement as well as to attempt to correct the fracture
deformity, obtaining fracture reduction and fixation.
Painful bone tumors involving the vertebrae; metastatic
disease.
2.
Deep Venous Thrombosis:
Catheter Directed Thrombolysis is suggested for acute to subacute thrombus (optimal at less than 4 weeks in age).
Suggested for young patients with large clot burden or
worsening clot burden despite adequate anti-coagulation, or
those with severe symptoms with risk of causing ischemia of
lower extremity.
75% can be performed in single session. Some may require
overnight infusion in ICU, especially patients with more chronic
thrombus.
3.
Image Guided Biopsy or Drainage:
U/S guidance is usually used for biopsies of thyroid nodules,
head and neck nodules, and lymph nodes as well as for
thoracentesis and paracentesis.
CT guided biopsy is used for lung masses, abdominal or pelvic
masses, or bone lesions.
21
.
CT guidance is usually used for abscess and empyema drainages,
chest tube placement for hemothorax, or loculated pleural fluid
collections.
4.
Interventional Oncologic Radiation Therapies:
Hepatic Artery Chemoembolization is an Angiogram of the
hepatic artery with direct injection of chemotherapy into the
tumor blood supply.
Used with primary liver cancer (Hepatocellular Carcinoma, HCC),
or liver dominant metastatic disease.
Tumor-Multifocal, > 5cm in size if solitary, little to no extrahepatic disease.
CT or MRI Abdomen should be performed for planning.
Cryoablation is CT guided percutaneous treatment of renal cell
carcinoma.
Tumor-Solitary, usually < 3cm in size.
Used with patients with limited renal function/reserve (solitary
kidney, chronic renal disease, not yet on HD, syndromes with
high risk of multiple tumors).
5.
IVC Filters:
Indicated for patients with lower extremity DVT or PE with
absolute contraindication to anti-coagulation, major
complication to anti-coagulation, or failed anti-coagulation.
Good to use with high risk patients (trauma, burn), prior to
orthopedic or bariatric surgery, or with cancer.
Patients with poor cardiopulmonary reserve with large DVT.
Retrievable or permanent filters may be placed.
Risk of causing DVT increases after 2 years; therefore,
recommend placing retrievable filters and attempting to
remove them within 6 months.
22
6.
Peripheral Vascular Disease:
Non-invasive arterial evaluations include Ankle Brachial
Index (ABI), Segmental Pressure Measurements, Arterial
Doppler Waveforms, and Pulse-Volume Waveforms.
Used for screening high risk patients, for mild or moderate
symptoms, or to follow disease progression.
CT Angiogram or MR Angiogram indicated for acute
ischemia, moderate to severe symptoms, or with atypical
symptoms.
Angiogram indicated for patients with moderate to severe
disease, or with those already treated with more
conservative measures.
7.
Uterine Fibroids:
Uterine artery embolization is an alternative to surgery for the
treatment of symptomatic uterine fibroids.
MRI Pelvis without and with contrast is recommended.
8.
Venous Access (Port, PICC, Hickman):
Venous access is an important part of outpatient chemotherapy
and long-term antibiotic administration (e.g., osteomyelitis and
Lyme’s treatment).
23
Musculoskeletal Imaging
1.
AVN Hip:
Plain X-Rays: AP Pelvis and Frog-Leg Lateral of symptomatic hip.
 X-rays negative or equivocal proceed with MRI.
 X-rays positive; proceed with MRI if information is needed
on other hip or for surgical planning.
If MRI is contraindicated, then proceed with Bone Scan with
SPECT for radiographically occult AVN.
2.
Joint Injections:
The indications for joint or soft tissue aspiration and injection
fall into two categories: diagnostic and therapeutic.
 Diagnostic indications include the aspiration of fluid for
analysis and the assessment of pain relief and increased
range of motion as a diagnostic tool.
A common diagnostic indication for placing a needle in a
joint is the aspiration of synovial fluid for evaluation of infection or inflammatory and crystal-induced arthropathies.
A second diagnostic indication involves the injection of a
local anesthetic to confirm the presumptive diagnosis
through symptom relief of the affected joint.
 Therapeutic indications include the delivery of local anesthetics for pain relief and the delivery of corticosteroids for
suppression of inflammation.
Therapeutic indications for joint or soft tissue aspiration
and injection include decreased mobility and pain, and the
injection of medication as a therapeutic adjunct to other
forms of treatment.
Therapeutic injection with corticosteroids should always
be viewed as adjuvant therapy.
24
These injections should never be undertaken without diagnostic definition and a specific treatment plan in place.
3.
Joint Replacements:
Plain X-Rays
 Initial exam for loosening or infection; however, X-Ray has
limited sensitivity/specificity.
Bone Scan
 May be positive in asymptomatic patients up to 2 years
post-op.
Joint Aspiration
 Effective for infection diagnosis if Abx held more than 2
weeks.
Difficult Cases
 Use combined WBC and Marrow Nuclear Medicine imaging.
CT and MRI
 Better than plain X-Ray for granulomatous disease detection.
 CT is useful for component rotational alignment.
4.
Metastatic Bone Disease:
Plain X-Rays
 For known primary and focal pain.
WB Bone Scan
 For primary detection (unless PET-CT performed for staging).
 Plain X-Rays for Bone Scan abnormalities.
MRI, CT, or PET-CT for non-diagnostic X-Rays.
MRI without contrast for spine disease.
25
5.
Image Guided Biopsy:
Use for diagnosis.
Use with suspected recurrence.
Use to differentiate mets. vs. osteonecrosis in previously irradiated bone.
6.
Stress Fracture:
Plain X-Rays are recommended.
 If X-Rays are negative and it is non-emergent, then repeat
X-Rays in 10-14 days.
MRI is best in terms of sensitivity/specificity.
 Useful in athletes, elderly and those who depend on injured limb to work.
 MRI without contrast unless ambiguous findings or
associated soft tissue mass.
CT is occasionally needed to confirm diagnosis, particularly for
pelvic/sacrum insufficiency fracture.
7.
Suspected Osteomyelitis of the Foot in Diabetics:
Clinical suspicion with or without ulceration.
 Plain X-Rays.
 MRI without and with contrast if X-Rays are negative. (MRI
without contrast for low GFR.)
If MRI contraindicated, 3-Phase Bone Scan & WBC Scan.
8.
Soft Tissue Swelling - Questioning Charcot or Infection:
Plain X-Rays.
3-Phase Bone Scan for negative X-Rays and low suspicion for infection.
MRI for negative X-Rays and moderate risk of infection.
Use pathway 1 for suspected osteo. in other anatomic sites
without/with D.M.
26
Neurologic Imaging
1.
Acute Head/Face Trauma:
CT without contrast is first choice.
MRI is sometimes used for evaluation of the brain in the setting
of unexplained symptomology.
No role for plain X-Rays.
2.
Acute Spine Trauma:
Plain X-Rays are best used when the suspicion of significant injury
is low.
CT is the quickest and most accurate in acute setting to exclude
fracture. CT is also used when plain X-Rays are equivocal or to
further evaluate abnormalities noted on X-Rays.
MRI is used when neurologic symptom or deficit is not explained
by plain X-Rays or CT. MRI is also used to evaluate the spinal
cord in the setting of known fractures and with the unresponsive
patient.
3.
Cerebral Aneurysms:
CT without contrast for acute presentation when subarachnoid
hemorrhage is suspected.
MRI and MRA Head (usually without contrast) in non-emergency
situations.
Head CTA (CT angiography with contrast) when in acute setting
for diagnosis and operative planning, or if MRI is contraindicated
in non-emergent setting.
Angiography used to further evaluate known aneurysm, or to detect tiny aneurysm when MRA/CTA is negative and clinical suspicion remains very high.
27
4.
Cerebral Metastases/Cerebral Tumor:
MRI with gadolinium is most sensitive and specific, request perfusion especially for treated (irradiated) tumors.
CT with and without contrast when MRI is contraindicated.
PET-CT.
5.
Chronic Back Pain:
MRI of the lumbar spine without contrast.
CT Myelogram if MRI is contraindicated or nondiagnostic.
Non-Myelographic CT can be performed as well if Myelogram is
also contraindicated, but this is not as sensitive or specific.
If suspicion of tumor (metastatic disease), infection, or if patient
is immunosuppressed, MRI with and without contrast.
In the post-operative spine, MRI with and without contrast to
evaluate for scar tissue.
6.
Chronic Intractable Epilepsy or New-Onset Seizures
Children/Teens:
MRI is first choice. Please include "epilepsy/seizure" when requesting the study (High resolution coronal T2-weighted imaging
of the hippocampi will be added for detection of mesial temporal
sclerosis).
If not typical febrile seizure, CT in the acute setting to exclude
hemorrhage, mass, or other cause of seizure.
7.
New-Onset Adult Seizures:
MRI is first choice. Contrast is generally added for adults with
new seizures.
CT in the acute setting to exclude intracranial hemorrhage or
other acute process, or if MRI is contraindicated.
28
8.
Dementia:
PET-CT is the most sensitive test for Alzheimer’s disease;
Medicare approved indication, CPT 78608.
MRI is most useful in excluding other causes of dementia (e.g.
multi-infarct dementia).
CT should be used if MRI is contraindicated.
9.
Demyelinating Disease:
MRI with and without contrast is exam of choice. Please specify
suspicion of, or history of, demyelinating disease when requesting the study (Sagittal and/or coronal FLAIR and STIR imaging will
be added).
CT with contrast when MRI contraindicated.
10. Encephalitis:
MRI with and without contrast is best.
CT with contrast if MRI is contraindicated.
11. Nasal CSF Leak (CSF Rhinorrhea):
Unenhanced high-resolution facial bone CT in the setting of
rhinorrhea suspicious for CSF leak.
CT cisternography (CT of the sinuses after intrathecal injection of
myelographic contrast) may be used to document the specific location of the leak when needed.
Radionuclide cisternogram, (measuring activity in cotton pledgets
inserted by ENT service in the nasal cavities after intrathecal injection of radionuclide) for slow leak.
12. Normal-Pressure Hydrocephalus:
MRI to evaluate for other causes of symptoms, findings to correlate with clinical diagnosis of NPH, or to evaluate CSF flow dynamics (if specifically requested).
29
CT used when MRI is contraindicated.
Radionuclide cisternogram often used.
13. Sellar and Juxtasellar Lesions:
MRI with and without contrast is exam of choice. Please specify
Pituitary MRI when requesting the study (High resolution T1
weighted imaging of the pituitary without and with contrast will
be added).
14. Spinal CSF Leak:
Radionuclide cisternogram is first choice.
MRI may be used to clarify etiology of leak if leak is demonstrated
in a specific location on Radionuclide cisternogram.
15. Stroke:
CT without contrast is first choice in the acute setting.
After CT, MRI can be performed to confirm and better characterize acute infarctions, old infarctions, and chronic ischemic disease.
MRI is also superior to CT for detection of posterior fossa infarctions, very early infarctions, or small infarcts. MRI is also superior
to CT in the detection of mimickers of ischemic disease.
MRA is used to evaluate vascular luminal compromise.
CTA if MRA is contraindicated.
16. Vascular Malformations:
Unenhanced CT used for acute presentation when hemorrhage is
suspected.
MRI with MRA Head (usually without contrast) in non-emergency
situations.
CTA Head (CT angiography with contrast) when MRI is contraindicated, or in acute setting.
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Angiography can be used to further evaluate vascular malformation detected by MRI/CT, or when MRI/CTA is negative and
clinical suspicion remains very high.
17. Vasculitis:
MRI Head with MRA (usually without contrast) in non-emergency
situations.
CT Head with CTA (CT angiography with contrast) when MRI is
contraindicated.
Angiography used when MRI/CT is negative and clinical suspicion
remains very high.
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Pediatric Imaging
1.
Abdominal and Pelvic Masses:
Plain X-Rays (bowel gas patterns/calcifications or constipation).
After plain X-Rays, U/S is primary modality for evaluation of an
abdominal or pelvic mass.
For older pediatric patients with indeterminate or non-diagnostic
U/S, use CT or MRI.
2.
Constipation (r/o Hirschprungs):
Order un-prepped single contrast barium enema.
GI/Rectal bleeding: Single contrast barium enema (must have
bowel prep prior to exam).
3.
Failure to Thrive:
UGI and small bowel follow through.
4.
Hip Instability/Dysplasia:
If under 6 months, perform Hip U/S. If over 6 months, perform
AP/Frog-Leg Pelvis X-Ray.
Hip dysplasia: If under 6 months, order Hip U/S. If over 6
months, order AP/Frog-Leg Pelvis X-Ray. This demonstrates both
hips on the same image for comparison.
Abnormality of neonatal back (sacral dimple, spinal hemangioma,
hairy patch): If under 6 months, order Spinal U/S to be followed
by AP/Lateral Lumbosacral Spine X-Ray. If over 6 months, order
sedated non-contrast MRI.
5.
Infantile Emesis:
If pyloric stenosis is suspected, do Pyloric U/S.
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If bilious emesis, then suspect obstruction and/or malrotation
and do urgent UGI series followed by Gastroview contrast enema
if needed.
If excessive GE reflux is suspected, consider UGI to exclude
anatomic causes.
If there is emesis plus failure to thrive, do UGI and small bowel
follow through.
6.
Non-Accidental Trauma (NAT):
If under two years of age, obtain NAT osseous survey plus noncontrast head CT.
If over two years of age, obtain Chest X-Ray. Then, consider
additional plain X-Rays and non-contrast Head CT as guided by
history and physical findings.
7.
Refusal to Bear Weight:
AP/Frog-Leg Pelvis and affected extremity. If hip effusion is
suspected at any age on physical exam or plain X-Rays, then
obtain Hip U/S.
8.
UTI Imaging:
Fluoroscopic VCUG and Renal U/S are recommended. If there is a
need to document pyelonephritis or renal scarring, then order
Nuclear Medicine Renal Cortical scan (DMSA).
9.
Pediatric Bowel Prep:
Clear liquids for 24 hours prior to examination.
Magnesium Citrate PO:
 2 doses are needed.
 First dose at 3pm or after school.
 Second dose at bed time the night before the test.
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Magnesium Citrate Dose Chart:
Age
Amount
< 1 yr.
none
1 - 3 yrs.
1.5 oz.
3 - 5 yrs.
2.5 oz.
6 - 8 yrs.
3 oz.
9 - 12yrs.
4 oz.
13 - 18yrs.
5 oz.
Clear liquids up until four hours before test, then no food or drink
for four hours before the test.
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Locations and Services Offered
Valley Regional Imaging (VRI)
3186 Village Drive, Suite 101
Fayetteville, NC 28304
(910) 323-2209
www.valleyregionalimaging.com
Carolina Regional Radiology (CRR) – Interventional Radiology Clinical
Practice
1301 Medical Drive
Fayetteville, NC 28304
(910) 486-5700
www.crrnc.com
Carolina Regional Radiology (CRR) – Angier Imaging Center
169 Rawls Road
Angier, NC 27501
(919)331-2001
www.crrnc.com
Affiliated Hospitals
Cape Fear Valley Medical Center
1638 Owen Drive
Fayetteville, NC 28304
Betsy Johnson Regional Hospital
800 Tilghman Drive
Dunn, NC 28335
Columbus Regional Healthcare System
500 Jefferson Street
Whiteville, NC 28472
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Compassionate Care, Quality Imaging
Harry Ameredes, MD
Terri Zacco, DO
David Fisher, MD
David Allison, MD
Richard Falter, MD
Richard Roux, MD
Max Faykus, MD
Mark Zalaznik, MD
Jeffrey Kotzan, MD
George Binder, MD Leroy Roberts Jr., MD
Grant Yanagi, MD
James Shearer, MD Tereza Poghosyan, MD Fred Caruso, MD
Sheryl Jordan, MD
Demir Bastug, MD Thomas Meakem III, MD
Beverly Davis, MD
Frank Graybeal Jr., MD
Ali Nasim, MD
Bruce Distell, MD