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Judge the appropriateness of administering a Magnetic Resonance Imaging head without Intravenous contrast on a patient with the following characteristics: child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging.
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may be appropriate
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[{'PMID': 27585209, 'Study Quality': '4'}, {'PMID': 23966248, 'Study Quality': '4', 'title': 'Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children.', 'abstract': 'The pseudotumor cerebri syndrome (PTCS) may be primary (idiopathic intracranial hypertension) or arise from an identifiable secondary cause. Characterization of typical neuroimaging abnormalities, clarification of normal opening pressure in children, and features distinguishing the syndrome of intracranial hypertension without papilledema from intracranial hypertension with papilledema have furthered our understanding of this disorder. We propose updated diagnostic criteria for PTCS to incorporate advances and insights into the disorder realized over the past 10 years.', 'publication': 'Neurology'}]
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limited
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usually appropriate
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may be appropriate (disagreement)
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may be appropriate
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usually not appropriate
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C
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Determine the appropriateness of administering a Computed Tomography neck without Intravenous contrast on a patient with the following characteristics: unilateral isolated palatal or vocal cord paralysis or both (vagal nerve, CN X). Initial imaging.
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may be appropriate
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[{'PMID': 27670956, 'Study Quality': '4', 'title': 'Repeat Imaging in Idiopathic Unilateral Vocal Fold Paralysis: Is It Necessary?', 'abstract': 'OBJECTIVE: Imaging plays a critical role in the evaluation of patients presenting with unilateral vocal fold paresis or paralysis of unknown etiology. In those with idiopathic unilateral vocal fold paralysis (iUVFP), there is no consensus regarding the need or timing of repeat imaging. This study seeks to establish the rate of delayed detection of alternate etiologies for these patients to determine if and when imaging should be repeated.\nMETHODS: Retrospective chart review was conducted identifying patients at our institution with vocal fold movement impairment between 1998 and 2014. Idiopathic paralysis was diagnosed if physical examination, laryngoscopy, and initial imaging excluded a cause. Demographic data, length of follow-up, and the presence of late lesions were noted. Time to detection was plotted using the Kaplan-Meier method.\nRESULTS: Of 3210 patients reviewed, 207 had a diagnosis of iUVFP. Of these patients, 8 went on to develop alternate diagnoses, including pulmonary disease, skull-base and laryngeal neoplasms, and thyroid malignancy. In Kaplan-Meir analysis, 90% remained "idiopathic" at 5 years of follow-up. The mean time to detection was 27 months.\nCONCLUSIONS: Patients initially diagnosed with iUVFP may have an occult cause that later becomes evident. We recommend repeat imaging within 2 years after diagnosis, but this is likely unnecessary beyond 5 years.', 'publication': 'Ann Otol Rhinol Laryngol'}, {'PMID': 16301111, 'Study Quality': '3', 'title': 'Arytenoid cartilage dislocation: a 20-year experience.', 'abstract': 'Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.', 'publication': 'J Voice'}, {'PMID': 27601300, 'Study Quality': '2', 'title': 'Cost-effectiveness of routine computed tomography in the evaluation of idiopathic unilateral vocal fold paralysis.', 'abstract': 'OBJECTIVES/HYPOTHESIS: To evaluate the cost-effectiveness of routine computed tomography (CT) in individuals with unilateral vocal fold paralysis (UVFP) STUDY DESIGN: Health Economics Decision Tree Analysis METHODS: A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of CT imaging in UVFP patients. Univariate sensitivity analysis was utilized to calculate what the probability of having an etiology of the paralysis discovered would have to be to make CT with contrast more cost-effective than no imaging. We used two studies examining findings in UVFP patients. The decision pathways were utilizing CT neck with intravenous contrast after diagnostic laryngoscopy versus laryngoscopy alone. The probability of detecting an etiology for UVFP and associated costs were extracted to construct the decision tree. The only incorrect diagnosis was missing a mass in the no-imaging decision branch, which rendered an effectiveness of 0.\nRESULTS: The ICER of using CT was $3,306, below most acceptable willingness-to-pay (WTP) thresholds. Additionally, univariate sensitivity analysis indicated that at the WTP threshold of $30,000, obtaining CT imaging was the most cost-effective choice when the probability of having a lesion was above 1.7%. Multivariate probabilistic sensitivity analysis with Monte Carlo simulations also showed that at the WTP of $30,000, CT scanning is more cost-effective, with 99.5% certainty.\nCONCLUSIONS: Particularly in the current healthcare environment characterized by increasing consciousness of utilization defensive medicine, economic evaluations represent evidence-based findings that can be employed to facilitate appropriate decision making and enhance physician-patient communication. This economic evaluation strongly supports obtaining CT imaging in patients with newly diagnosed UVFP.\nLEVEL OF EVIDENCE: 2c. Laryngoscope, 2016 127:440-444, 2017.', 'publication': 'Laryngoscope'}, {'PMID': 27085701, 'Study Quality': '2', 'title': 'Feasibility of vocal fold abduction and adduction assessment using cine-MRI.', 'abstract': 'OBJECTIVE: Determine feasibility of vocal fold (VF) abduction and adduction assessment by cine magnetic resonance imaging (cine-MRI) METHODS: Cine-MRI of the VF was performed on five healthy and nine unilateral VF paralysis (UVFP) participants using an axial gradient echo acquisition with temporal resolution of 0.7 s. VFs were continuously imaged with cine-MRI during a 10-s period of quiet respiration and phonation. Scanning was repeated twice within an individual session and then once again at a 1-week interval. Asymmetry of VF position during phonation (VF phonation asymmetry, VFPa) and respiration (VF respiration asymmetry, VFRa) was determined. Percentage reduction in total glottal area between respiration and phonation (VF abduction potential, VFAP) was derived to measure overall mobility. An un-paired t-test was used to compare differences between groups. Intra-session, inter-session and inter-reader repeatability of the quantitative metrics was evaluated using intraclass correlation coefficient (ICC).\nRESULTS: VF position asymmetry (VFPa and VFRa) was greater (p=0.012; p=0.001) and overall mobility (VFAP) was lower (p=0.008) in UVFP patients compared with healthy participants. ICC of repeatability of all metrics was good, ranged from 0.82 to 0.95 except for the inter-session VFPa (0.44).\nCONCLUSION: Cine-MRI is feasible for assessing VF abduction and adduction. Derived quantitative metrics have good repeatability.\nKEY POINTS: • Cine-MRI is used to assess vocal folds (VFs) mobility: abduction and adduction. • New quantitative metrics are derived from VF position and abduction potential. • Cine-MRI able to depict the difference between normal and abnormal VF mobility. • Cine-MRI derived quantitative metrics have good repeatability.', 'publication': 'Eur Radiol'}, {'PMID': 25518905, 'Study Quality': '4', 'title': 'Routine computed tomography in the evaluation of vocal fold movement impairment without an apparent cause.', 'abstract': 'OBJECTIVE: Routine computed tomography (CT) for vocal fold movement impairment (VFMI) without an apparent cause is common. However, given increased cancer risk associated with ionizing radiation exposure, our purpose is to evaluate the utility of routine scans for these patients.\nSTUDY DESIGN: Retrospective case series.\nSETTING: Houston, Texas.\nSUBJECTS AND METHODS: A 5-year review of patients with VFMI diagnosed at an academic institution was conducted. For patients without an apparent cause (eg, recent head, neck, or cardiothoracic surgery or known malignancy), CT head/neck and chest was performed to evaluate the recurrent laryngeal nerve course. Data included demographics, symptoms, radiography, and interventions. Statistical analyses were performed via χ(2) analysis.\nRESULTS: Of 406 patients with VFMI, 47 (11%) patients had no apparent cause clinically. Routine CT revealed abnormalities in 10 (21%) patients, of which only 3 (6%) could account for VFMI: benign thyroid adenoma (1), papillary thyroid cancer (1), and an esophageal mass (1). The most common lesion detected involved the thyroid. Demographic data and symptom type were not significantly associated with detection of a VFMI-attributable lesion on CT. Overall, routine CT did not identify a focal etiology in 94% patients with VFMI without an apparent cause.\nCONCLUSION: Routine pan-CT evaluation failed to reveal an etiology in 94% of patients with VFMI without an apparent cause. Patients may be subjected to health risks associated with radiation exposure without significant diagnostic benefit. Further studies should consider more judicious use of CT in the context of risk factors and safer imaging modalities as the initial diagnostic step.', 'publication': 'Otolaryngol Head Neck Surg'}, {'PMID': 31485732, 'Study Quality': '4', 'title': 'Three-dimensional imaging of vocalizing larynx by ultra-high-resolution computed tomography.', 'abstract': 'PURPOSE: Ultra-high-resolution computed tomography (UHRCT) is an emerging imaging technology that is able to achieve simultaneous 160 slices with super-thin 0.25\xa0mm thickness. The purpose of this study was to assess the feasibility of UHRCT to visualize laryngeal structure and kinetics.\nMETHODS: Three normal volunteers and three patients with unilateral vocal fold paralysis (UVFP) were incorporated in this case series. First, images were taken under five conditions in normal volunteers. Five tasks consisted of (1) air inspiration through the nose (IN), (2) breath holding (BH), (3) sustained vowel /i:/ phonation (IP), (4) humming phonation (HP), and (5) forced glottic closure during exhalation (FC). Three-dimensional CT images of arytenoid and cricoid cartilages, as well as virtual laryngoscopic images, were reconstructed using UHRCT data. Reconstructed images were compared among five conditions to assess the best tasks to picture laryngeal kinetics. Second, pre- and post-phonosurgical images were examined in UVFP patients to evaluate potential role of UHRCT to assess laryngeal pathology in hoarse patients.\nRESULTS: Among the five conditions, IN and IP conditions were considered suitable to visualize laryngeal structure at rest and during phonation, respectively. Kinetic abnormalities including asymmetric motion of arytenoid cartilages were elucidated in UVFP patients, and virtual endoscopy visualized the clinically invisible posterior three-dimensional glottic chinks. Furthermore, UHRCT was useful to understand changes in laryngeal structure achieved by phonosurgery.\nCONCLUSIONS: UHRCT is an emerging imaging technology that can be used for minimally invasive visualization and assessment of laryngeal structure and kinetics. Future studies to assess more number of patients with laryngeal dysfunction are warranted.', 'publication': 'Eur Arch Otorhinolaryngol'}, {'PMID': 31283463, 'Study Quality': '4', 'title': 'Midbrain, Pons, and Medulla: Anatomy and Syndromes.', 'abstract': 'The anatomy of the brainstem is complex. It contains numerous cranial nerve nuclei and is traversed by multiple tracts between the brain and spinal cord. Improved MRI resolution now allows the radiologist to identify a higher level of anatomic detail, but an understanding of functional anatomy is crucial for correct interpretation of disease. Brainstem syndromes are most commonly due to occlusion of the posterior circulation or mass effect from intrinsic space-occupying lesions. These syndromes can have subtle imaging findings that may be missed by a radiologist unfamiliar with the anatomy or typical manifesting features. This article presents the developmental anatomy of the brainstem and discusses associated pathologic syndromes. Congenital and acquired syndromes are described and correlated with anatomic locations at imaging, with diagrams to provide a reference to aid in radiologic interpretation. ©RSNA, 2019.', 'publication': 'Radiographics'}, {'PMID': 22582356, 'Study Quality': '4', 'title': 'Unilateral vocal cord paralysis: a review of CT findings, mediastinal causes, and the course of the recurrent laryngeal nerves.', 'abstract': 'Vocal cord paralysis (VCP) may be caused by a variety of mediastinal disease entities, including various neoplastic, inflammatory, and vascular conditions, and may be the presenting symptom of an otherwise clinically occult disease. Familiarity with the spectrum of thoracic diseases that can result in VCP and inclusion of the mediastinum to the level of the aorticopulmonary window (left side) or brachiocephalic artery (right side) in computed tomographic (CT) studies performed for VCP are essential. VCP can be reliably identified at CT by recognizing key findings at the level of the true vocal cords and aryepiglottic folds. Although there are a number of VCP mimics and imaging pitfalls, they can generally be avoided by carefully assessing the scan plane and level and evaluating for additional findings. By understanding and assessing the entire course of the vagus and recurrent laryngeal nerves, the radiologist can avoid missing causative lesions, many of which have a clinical significance far beyond that of the VCP itself.', 'publication': 'Radiographics'}, {'PMID': 29785934, 'Study Quality': '4', 'title': 'Imaging Modalities in the Etiologic Evaluation of Unilateral Vocal Fold Paralysis.', 'abstract': 'OBJECTIVE: This study aimed to investigate the roles of computed tomography (CT) and neck ultrasonography (US) in evaluating unilateral vocal fold paralysis (UVFP) of unknown etiology and to compare our results with those of other studies to assess the differences in etiology of UVFP.\nMETHODS: We investigated the medical records of 202 eligible patients with UVFP. In total, 168 underwent chest CT, 118 underwent neck CT, and 108 underwent head CT. One hundred and three patients were also evaluated with high-resolution neck US. The etiologic causes of UVFP were also determined.\nRESULTS: Of the 202 eligible patients, the occult cause of the UVFP was determined in 96 patients (47.5%). Idiopathic causes were the most common etiologies (n\u2009=\u2009106). In occult causes group, chest lesions were the most common diseases causing paralysis (52 cases) and included lung cancer (n\u2009=\u200928) and mediastinal malignancy (n\u2009=\u20098). More than half of the neck lesions were of thyroid origin. Of the 18 thyroid lesions, 12 were thyroid malignancies. Chest CT had an intermediate yield of 30.9% (52 of 168). Neck US had a diagnostic yield close to that of neck CT (26.2%).\nCONCLUSION: UVFP may result mainly from idiopathic, lung cancer, mediastinal, and thyroid malignancies. The initial use of neck US as an alternative to CT may be advocated for the determination of diseases resulting in UVFP.', 'publication': 'J Voice'}, {'PMID': 22965930, 'Study Quality': '4', 'title': 'Computed tomography has low yield in the evaluation of idiopathic unilateral true vocal fold paresis.', 'abstract': 'OBJECTIVE/HYPOTHESIS: To determine the clinical yield of neck and chest computed tomography in the initial assessment of patients with idiopathic unilateral true vocal fold paresis.\nSTUDY DESIGN: Retrospective chart review.\nMETHODS: A retrospective chart review of consecutive adult patients with idiopathic unilateral true vocal fold paresis diagnosed by stroboscopy in a tertiary-care voice center from 2003 to 2010.\nRESULTS: There were 176 patients with unilateral vocal fold paresis of which 81 subjects had idiopathic unilateral true vocal fold paresis. Of these, 60 patients (74.1%) had a computed tomography workup. Fifty-nine patients (98.3%) had a normal computed tomography while one patient had a single mediastinal lymph node that was PET-CT negative. This demonstrates an initial 1.7% yield and ultimate 0% yield of the computed tomography workup.\nCONCLUSION: Our results suggest that computed tomography workup has a low yield for occult neck and mediastinal pathology in patients with idiopathic unilateral true vocal fold paresis. Chest and neck computed tomography may not be clinically beneficial provided the patient has good otolaryngologic and medical follow-up.', 'publication': 'Laryngoscope'}, {'PMID': 26156423, 'Study Quality': '4', 'title': 'Diagnostic Yield of Computed Tomography in the Evaluation of Idiopathic Vocal Fold Paresis.', 'abstract': 'OBJECTIVE: To determine the diagnostic yield of computed tomography (CT) in establishing an etiology in patients with idiopathic unilateral vocal fold paresis (IUVFP). To determine the proportion of CT scans yielding incidental findings requiring further patient management.\nSTUDY DESIGN: Case series with chart review.\nSETTING: Tertiary laryngology practice.\nSUBJECTS: Laryngology clinic patients under the care of the 2 senior authors.\nMETHODS: All clinic patients were identified who had a diagnosis of IUVFP and underwent CT of the skull base to the upper mediastinum from 2004 to 2014. Demographic, historical, examination, and investigation data were extracted. CT reports and endoscopic recordings were reviewed. Patients were excluded if there were insufficient clinical findings recorded or if there was a known neurologic disorder, complete vocal fold immobility, or bilateral involvement.\nRESULTS: A total of 174 patients with IUVFP who had also undergone contrast-enhanced CT were identified. Of the 174 patients, 5 had a cause for their paresis identified on CT. This equated to a diagnostic yield of 2.9% (95% confidence interval, 0.94% to 6.6%). Of the 174 patients, 48 had other incidental lesions identified that required further follow-up, investigation, or treatment. This equated to an incidental yield of 27.6% (95% confidence interval, 21.1% to 34.9%).\nCONCLUSION: This is the second and largest study to evaluate the diagnostic yield of CT in the evaluation of IUVFP. It demonstrates a low diagnostic yield and a high incidental yield. These findings suggest that the routine use of CT in the evaluation of idiopathic vocal fold paresis should be given careful consideration and that a tailored approach to investigation with good otolaryngologic follow-up is warranted.', 'publication': 'Otolaryngol Head Neck Surg'}]
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strong
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may be appropriate
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may be appropriate (disagreement)
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usually not appropriate
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usually appropriate
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A
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Scrutinize the appropriateness of providing a Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography whole body on a patient with the following characteristics: ovarian cancer screening. Premenopausal. High risk (personal history or family history or known or suspected genetic predisposition or elevated CA-125).
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usually not appropriate
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[]
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expert consensus
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may be appropriate
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may be appropriate (disagreement)
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usually appropriate
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usually not appropriate
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D
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Judge the appropriateness of administering a Midline catheter on a patient with the following characteristics: device selection: Acutely ill patient requiring infusion of vesicant medication, hemodynamic monitoring, and frequent blood draws for 2 weeks or shorter.
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may be appropriate
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[{'PMID': 34553435, 'Study Quality': '2'}, {'PMID': 24811603, 'Study Quality': '1'}]
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strong
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may be appropriate
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may be appropriate (disagreement)
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usually not appropriate
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usually appropriate
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A
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Investigate the appropriateness of performing a Computed Tomography maxillofacial with Intravenous contrast on a patient with the following characteristics: pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia. Suspect midface injury. Initial imaging following primary survey.
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usually not appropriate
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[{'PMID': 29320322, 'Study Quality': '4'}, {'PMID': 30454777, 'Study Quality': '4'}, {'PMID': 28941512, 'Study Quality': '4'}, {'PMID': 27618328, 'Study Quality': '4'}, {'PMID': 27761894, 'Study Quality': '4'}, {'PMID': 24183372, 'Study Quality': '4'}, {'PMID': 23322824, 'Study Quality': '4'}, {'PMID': 22472677, 'Study Quality': '4'}, {'PMID': 21377837, 'Study Quality': '4'}, {'PMID': 30007759, 'Study Quality': '4'}, {'PMID': 29922866, 'Study Quality': '4'}, {'PMID': 29903561, 'Study Quality': '4'}, {'PMID': 28941507, 'Study Quality': '4'}, {'PMID': 27348349, 'Study Quality': '4'}, {'PMID': 25639172, 'Study Quality': '4'}, {'PMID': 24138736, 'Study Quality': '4'}, {'PMID': 23498333, 'Study Quality': '4'}, {'PMID': 21617475, 'Study Quality': '4'}, {'PMID': 21111135, 'Study Quality': '4'}, {'PMID': 31345487, 'Study Quality': '4'}, {'PMID': 2017492, 'Study Quality': '4'}]
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limited
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usually appropriate
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may be appropriate
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usually not appropriate
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may be appropriate (disagreement)
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C
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Determine the appropriateness of executing a Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography skull base to mid-thigh on a patient with the following characteristics: chronic dyspnea. Suspected disease of the pleura or chest wall. Initial imaging.
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usually not appropriate
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[]
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expert consensus
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usually appropriate
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may be appropriate (disagreement)
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may be appropriate
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usually not appropriate
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D
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Scrutinize the appropriateness of providing a Fluoroscopy contrast enema on a patient with the following characteristics: palpable abdominal mass. Suspected abdominal wall mass. Initial imaging.
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usually not appropriate
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[{'PMID': 25064764, 'Study Quality': '4', 'title': 'Soft-tissue masses in the abdominal wall.', 'abstract': 'Masses involving the abdominal wall arise from a large number of aetiologies. This article will describe a diagnostic approach, imaging features of the most common causes of abdominal wall masses, and highly specific characteristics of less common diseases. A diagnostic algorithm for abdominal wall masses combines clinical history and imaging appearances to classify lesions.', 'publication': 'Clin Radiol'}, {'PMID': 23381506, 'Study Quality': '4', 'title': "The challenging image-guided abdominal mass biopsy: established and emerging techniques 'if you can see it, you can biopsy it'.", 'abstract': 'Image-guided percutaneous biopsy of abdominal masses is among the most commonly performed procedures in interventional radiology. While most abdominal masses are readily amenable to percutaneous biopsy, some may be technically challenging for a number of reasons. Low lesion conspicuity, small size, overlying or intervening structures, motion, such as that due to respiration, are some of the factors that can influence the ability and ultimately the success of an abdominal biopsy. Various techniques or technologies, such as choice of imaging modality, use of intravenous contrast and anatomic landmarks, patient positioning, organ displacement or trans-organ approach, angling CT gantry, triangulation method, real-time guidance with CT fluoroscopy or ultrasound, sedation or breath-hold, pre-procedural image fusion, electromagnetic tracking, and others, when used singularly or in combination, can overcome these challenges to facilitate needle placement in abdominal masses that otherwise would be considered not amenable to percutaneous biopsy. Familiarity and awareness of these techniques allows the interventional radiologist to expand the use of percutaneous biopsy in clinical practice, and help choose the most appropriate technique for a particular patient.', 'publication': 'Abdom Imaging'}, {'PMID': 16371582, 'Study Quality': '3', 'title': 'Distinguishing benign from malignant adrenal masses: multi-detector row CT protocol with 10-minute delay.', 'abstract': 'PURPOSE: To retrospectively evaluate the accuracy of precontrast attenuation, relative percentage washout (RPW), and absolute percentage washout (APW) in distinguishing benign from malignant adrenal masses at multi-detector row computed tomography (CT).\nMATERIALS AND METHODS: This HIPAA-compliant retrospective study had institutional review board approval; the need for informed consent was waived. One hundred twenty-two adrenal masses were evaluated in 99 patients (51 men, 48 women; age range, 37-86 years) who had undergone CT performed according to the study protocol and who either were given a pathologic diagnosis or underwent follow-up imaging. Unenhanced images were obtained before administration of 120 mL of an intravenous contrast agent with a 75-second scan delay. Delayed images were obtained after 10 minutes. RPW and APW were computed. Receiver operating characteristic (ROC) analysis was performed to compare mean attenuation and both RPW and APW. Analysis was first performed with the exclusion of pheochromocytomas, myelolipomas, and cysts. Precontrast attenuation criteria specific for benignity or malignancy were determined, and ROC analysis of results for the entire nonpheochromocytoma group was then performed.\nRESULTS: By using an RPW of 37.5% and excluding cysts and myelolipomas, all malignant lesions were detected with a sensitivity of 100% (17 of 17 lesions) and a specificity of 95% (90 of 95 lesions). Area under the binomial ROC curve (A(z)) values were 0.912, 0.985, and 0.892 for precontrast attenuation, RPW, and APW, respectively. Precontrast attenuation of less than 0 or more than 43 HU indicated benign and malignant entities, respectively. Incorporation of these criteria into the APW analysis yielded a sensitivity of 100% (17 of 17 lesions) and a specificity of 98% (93 of 95 lesions) for a threshold washout value of 52.0%. This attenuation-corrected APW generated the greatest A(z) value (ie, 0.988). Combining all the information available from the protocol yielded a sensitivity of 100% (17 of 17 lesions) and a specificity of 98% (98 of 100 lesions) for differentiating benign from malignant masses.\nCONCLUSION: Precontrast attenuation of less than 0 HU supercedes the washout profile in the evaluation of an individual adrenal mass. Noncalcified, nonhemorrhagic adrenal lesions with precontrast attenuation of more than 43 HU should be considered suspicious for malignancy.', 'publication': 'Radiology'}, {'PMID': 6561119, 'Study Quality': '4', 'title': 'Intravenous contrast bolus in computed tomography investigation of mass lesion.', 'abstract': 'Using bolus intravenous contrast (25-75 Renografin 60) and 5-second scanning capability, better definition of vascular anatomy as well as the vascular nature of mass lesions in the chest and abdomen could be demonstrated. The immediate higher concentration of iodine in vessels and organs following initial bolus, improves visualization of these structures dramatically when compared to drip-infusion technique. A description of the technique and examples are shown.', 'publication': 'Diagn Imaging Clin Med'}, {'PMID': 28004137, 'Study Quality': '3', 'title': 'Abdominal wall endometriosis: differentiation from other masses using CT features.', 'abstract': 'PURPOSE: To assess the utility of morphologic and quantitative CT features in differentiating abdominal wall endometriosis (AWE) from other masses of the abdominal wall.\nMETHODS: Retrospective IRB-approved study of 105 consecutive women from two institutions who underwent CT and biopsy/resection of abdominal wall masses. CTs were independently reviewed by two radiologists blinded to final histopathologic diagnoses. Associations between CT features and pathology were tested using Fisher\'s Exact Test. Sensitivity, specificity, positive, and negative predictive values were calculated. P values were adjusted for multiple variable testing.\nRESULTS: 24.8% (26/105) of patients had histologically proven abdominal wall endometriosis. The other most common diagnoses included adenocarcinoma NOS (21%; 22/105), desmoid (14.3%; 15/105), and leiomyosarcoma (8.6%; 9/105). CT features significantly associated with endometriosis for both readers were location below the umbilicus (P\xa0=\xa00.0188), homogeneous density (P\xa0=\xa00.0188), and presence of linear infiltration irradiating peripherally from a central soft tissue nodule (i.e., "gorgon" sign) (P\xa0<\xa00.0001). The highest combined sensitivity (0.69, 95% CI: 0.48-0.86) and specificity (0.97, 95% CI: 0.91-1.00) for both readers occurred for patients having all three of these features present. Border type (P\xa0=\xa00.0199) was only significant for R2, peritoneal extension (P\xa0=\xa00.0188) was only significantly for R1, and the remainder of features were insignificant (P\xa0=\xa00.06-60). There was overlap in Hounsfield\xa0units on non-contrast CT (N\xa0=\xa026) between AWE (median: 45HU, range: 39-54) and other abdominal wall masses (median: 38.5HU, range: 15-58).\nCONCLUSION: CT features are helpful in differentiating AWE from other abdominal wall soft tissue masses. Such differentiation may assist decisions regarding possible biopsy and treatment planning.', 'publication': 'Abdom Radiol (NY)'}, {'PMID': 15728607, 'Study Quality': '3', 'title': "MDCT of abdominal wall hernias: is there a role for valsalva's maneuver?", 'abstract': "OBJECTIVE: Our objective was to evaluate the role of Valsalva's maneuver during MDCT for the diagnosis and characterization of abdominal wall hernias.\nSUBJECTS AND METHODS: From September 2002 to May 2003, 100 consecutive patients (37 men and 63 women; mean age, 53 years) with suspected anterior abdominal wall hernias underwent 4-, 8-, or 16-MDCT with and without Valsalva's maneuver. Patients received both oral and IV contrast material. On a workstation, three independent reviewers evaluated each scan obtained during rest and during Valsalva's maneuver for the following parameters: anteroposterior (AP) diameter of the abdomen; presence, location, and contents of the hernia; and transverse diameter of the fascial defect. The scans were compared to assess for changes in hernia size and contents and to determine whether the hernia would have been overlooked without Valsalva's maneuver. Fisher's exact test, the McNemar test, and Cohen's kappa coefficient were used to assess for significant differences.\nRESULTS: The three reviewers identified a mean of 72 abdominal wall hernias (72%). The reviewers agreed (kappa = 0.723) with respect to the presence of a hernia. AP diameters increased an average of 1.33 cm during Valsalva's maneuver (p < 0.001). The transverse diameter of the fascial defect increased an average of 0.66 cm and the AP diameter of the hernia sac increased an average of 0.79 cm during Valsalva's maneuver (p < 0.001). Fifty percent of the hernias became more apparent with Valsalva's maneuver. Ten percent of the hernias could be detected only on the scan obtained during Valsalva's maneuver. Conversely, in no patients was the hernia detected only on the rest scan.\nCONCLUSION: As opposed to scans obtained at rest, scans obtained during Valsalva's maneuver aid in the detection and characterization of suspected abdominal wall hernias. A single scan obtained during Valsalva's maneuver is sufficient to detect 100% of anterior abdominal wall hernias identified on CT.", 'publication': 'AJR Am J Roentgenol'}, {'PMID': 29571558, 'Study Quality': '4', 'title': 'Abdominal Wall Masses: CT Findings and Clues to Differential Diagnosis.', 'abstract': 'The abdominal wall does not comprise a distinct organ, and is often cursorily evaluated on CT. However, it is affected by many different pathological processes. These may be categorized according to their underlying etiology-trauma, infection or inflammation, iatrogenic and neoplastic process-or according to the abdominal wall layer they affect. We chose instead to group these lesions into 6 distinct categories based on their CT characteristic density: solid, infiltrative, hypervascular, fluid, fat, and bone density lesions. We highlight throughout the article the importance of integrating pertinent clinical history to narrow the differential diagnosis.', 'publication': 'Semin Ultrasound CT MR'}]
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expert consensus
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may be appropriate
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usually not appropriate
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usually appropriate
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may be appropriate (disagreement)
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B
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Scrutinize the appropriateness of providing a Magnetic Resonance Angiography head and neck without Intravenous contrast on a patient with the following characteristics: new focal neurologic defect, fixed or worsening. Longer than 6 hours. Suspected stroke.
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usually appropriate
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[]
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not specified
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usually appropriate
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may be appropriate (disagreement)
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may be appropriate
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usually not appropriate
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A
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Survey the appropriateness of delivering a Magnetic Resonance Imaging hand without and with Intravenous contrast on a patient with the following characteristics: initial radiographs showing metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joint malalignment in the absence of fracture. Next imaging study.
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usually not appropriate
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[{'PMID': 11818612, 'Study Quality': '3', 'title': 'MR imaging of the metacarpophalangeal joints of the fingers: part II. Detection of simulated injuries in cadavers.', 'abstract': 'PURPOSE: To evaluate and compare conventional magnetic resonance (MR) imaging and MR arthrography in the diagnosis of the most common traumatic metacarpophalangeal (MCP) joint injuries, which were created surgically in cadavers.\nMATERIALS AND METHODS: Injuries to various MCP joint structures were surgically created randomly in 28 fingers of seven human cadaveric hands. Injuries to the main collateral ligaments (CLs) (n = 12), accessory CL (n = 15), sagittal band (n = 14), transverse fibers of the extensor hood (n = 5), first annular pulley (n = 16), deep transverse metacarpal ligament (DTML) (n = 5), and palmar plate (n = 10) were analyzed. Conventional MR images and MR arthrograms were evaluated, with differences in interpretation resolved in consensus. The sensitivities, specificities, and accuracies of both MR imaging methods were determined, and the differences were tested for significance by using the McNemar test.\nRESULTS: Sensitivity was 28.6%-93.8% with conventional MR imaging versus 50.0%-93.3% with MR arthrography. Specificity was 66.7%-100% with conventional MR imaging versus 83.3%-100% with MR arthrography. Although the MR arthrographic results usually were higher, the differences were not significant. The kappa values for interobserver agreement were 0.314-0.638 for conventional MR imaging versus 0.364-1.00 for MR arthrography. Sensitivity for the detection of lesions of the main and accessory CLs and the first annular pulley was slightly higher than that for the detection of lesions of the extensor hood, DTML, and palmar plate structures.\nCONCLUSION: MR imaging and MR arthrography enable the diagnosis of simulated MCP joint injuries. MR arthrography does not have a significant advantage over conventional MR imaging.', 'publication': 'Radiology'}, {'PMID': 11012445, 'Study Quality': '3', 'title': 'Pulley system in the fingers: normal anatomy and simulated lesions in cadavers at MR imaging, CT, and US with and without contrast material distention of the tendon sheath.', 'abstract': 'PURPOSE: To describe the normal anatomy of the finger flexor tendon pulley system, with anatomic correlation, and to define criteria to diagnose pulley abnormalities with different imaging modalities.\nMATERIALS AND METHODS: Three groups of cadaveric fingers underwent computed tomography (CT), magnetic resonance (MR) imaging, and ultrasonography (US). The normal anatomy of the pulley system was studied at extension and flexion without and with MR tenography. Pulley lengths were measured, and anatomic correlation was performed. Pulley lesions were created and studied at flexion, extension, and forced flexion. Two radiologists reviewed the studies in blinded fashion.\nRESULTS: MR imaging demonstrated A2 (proximal phalanx) and A4 (middle phalanx) pulleys in 12 (100%) of 12 cases, without and with tenography. MR tenography showed the A3 (proximal interphalangeal) and A5 (distal interphalangeal) pulleys in 10 (83%) and nine (75%) cases, respectively. US showed the A2 pulley in all cases and the A4 pulley in eight (67%). CT did not allow direct pulley visualization. No significant differences in pulley lengths were measured at MR, US, or pathologic examination (P: =.512). Direct lesion diagnosis was possible with MR imaging and US in 79%-100% of cases, depending on lesion type. Indirect diagnosis was successful with all methods with forced flexion.\nCONCLUSION: MR imaging and US provide means of direct finger pulley system evaluation.', 'publication': 'Radiology'}, {'PMID': 8029417, 'Study Quality': '3', 'title': 'Acute trauma of the extensor hood of the metacarpophalangeal joint: MR imaging evaluation.', 'abstract': 'PURPOSE: To assess detectability of the components of the extensor hood, especially the sagittal bands, with magnetic resonance (MR) imaging in normal and injured metacarpophalangeal (MP) joints.\nMATERIALS AND METHODS: T2*-weighted, T1-weighted, and contrast material-enhanced T1-weighted images were obtained of 54 normal MP joints (108 sagittal bands). The ability to detect the sagittal bands with each sequence was rated for three observers. These same sequences were used for MR imaging of nine patients with acute MP injury. Seven patients underwent surgery.\nRESULTS: The sensitivity of MR imaging for the detection of normal sagittal bands was 0.89-0.92 for T2*-weighted images, 0.80-0.88 for T1-weighted images, and 0.81-0.91 for contrast-enhanced T1-weighted images. MR imaging findings in patients with extensor hood injury included irregularity, poor definition, and increased signal intensity or uptake of contrast material by structures in and around the extensor hood. All MR imaging findings correlated well with those of surgery.\nCONCLUSION: MR imaging is accurate for determination of the presence and severity of injury to the extensor hood.', 'publication': 'Radiology'}, {'PMID': 8623637, 'Study Quality': '4', 'title': 'Flexor tendon tears in the hand: use of MR imaging to diagnose degree of injury in a cadaver model.', 'abstract': 'OBJECTIVE: Treatment of flexor tendon lacerations of the finger partly depends on the degree of injury, which is difficult to determine clinically. We used a cadaver model to investigate the potential of MR imaging in evaluating these injuries.\nMATERIALS AND METHODS: A scalpel was drawn transversely across the volar surface of four cadaver hands, producing various flexor tendon injuries. MR imaging of each hand was performed using axial two-dimensional spin-echo and three-dimensional gradient-recalled-echo sequences. The three-dimensional data sets were interactively reformatted along the long axis of each tendon. The hands were then dissected; injury to each digit was categorized, measured, and compared with the prospective MR interpretations.\nRESULTS: Twelve high-grade flexor tendon tears (10 complete tears, with 1- to 14-mm separation of the torn ends, and two partial tears involving 50% or more of the total tendon cross-sectional area) and two partial tears of less than 50% of tendon area were produced; four tendons were not injured. Using MR imaging, we diagnosed 11 of the 12 high-grade lesions (those involving at least 50% of the total tendon cross-sectional area); the MR images did not show one complete tear whose separation measured 2 mm long at dissection. All intact tendons were correctly identified. We underestimated the extent of five lesions but overestimated none. Using the reformatted images, we reduced the number of errors that we would have made interpreting the transverse images alone.\nCONCLUSION: In this cadaver model, using MR imaging we accurately distinguished different degrees of flexor tendon tears. The potential of this technique for noninvasively diagnosing flexor tendon injury in patients awaits clinical studies.', 'publication': 'AJR Am J Roentgenol'}, {'PMID': 9867179, 'Study Quality': '3', 'title': 'Closed ruptures of the flexor digitorum tendons: MRI evaluation.', 'abstract': 'OBJECTIVE: To assess the MRI findings in cases of closed rupture of the flexor digitorum tendons (FDT).\nPATIENTS AND DESIGN: Ten patients with a clinical suspicion of rupture of FDT underwent MRI before surgery. None of the patients presented a skin injury. Fingers were imaged using axial T1-weighted SE sequences, three-dimensional GE images, and curved reconstructions.\nRESULTS: Twelve FDT had surgical confirmation of rupture. Flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons were more frequently ruptured (n=8) than flexor digitorum superficialis (FDS) tendons (n=4). MR images accurately depicted the level of the rupture. The gap between the tendon ends (mean 45 mm, range 21-70 mm) was assessed best with curved reconstructions and was well correlated with the surgical findings. The proximal end mainly retracted into the palm or the carpal tunnel (n=8), and less frequently into the digital canal (n=4). In two cases, the proximal end curled up in the palm, clinically simulating a rupture of a lumbrical muscle in one case. MRI also showed the appearance of the adjacent tendons.\nCONCLUSION: MRI accurately depicted the level of rupture and the gap between the tendon ends, which assisted the surgical choice between suture, graft or tendon transfer.', 'publication': 'Skeletal Radiol'}]
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limited
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usually not appropriate
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may be appropriate
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usually appropriate
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may be appropriate (disagreement)
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A
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Review the appropriateness of conducting a Magnetic Resonance Imaging hip without Intravenous contrast on a patient with the following characteristics: chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study.
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usually appropriate
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[{'PMID': 15800516, 'Study Quality': '2', 'title': 'Magnetic resonance imaging of the hip: detection of labral and chondral abnormalities using noncontrast imaging.', 'abstract': 'PURPOSE: Traditional imaging techniques have limited ability to detect subtle chondral and labral injuries of the hip. We performed a retrospective review of patients who underwent magnetic resonance imaging (MRI) of the hip and subsequent hip arthroscopy in order to evaluate the ability of optimized, noncontrast MRI to identify tears of the acetabular labrum and defects in articular cartilage.\nTYPE OF STUDY: Retrospective review of a consecutive sample.\nMETHODS: Between January 1997 and July 2000, 92 patients had MRI of the hip, followed by arthroscopic surgery of that hip by 1 of 2 surgeons (R.B., D.E.P.). Two musculoskeletal MR radiologists blinded to the initial MRI and surgical findings, independently interpreted the studies, looking for the location and degree of articular cartilage and acetabular labral pathology.\nRESULTS: Of the 92 patients studied, each of 2 radiologists correctly identified 83 (94%) and 84 (95%) of the 88 labral tears present at surgery, respectively. There was 92% interobserver agreement on the MRI studies. For articular cartilage defects on the femoral head and acetabulum, there was good agreement (92% and 86% within 1 grade) between MRI and surgical grading and between the 2 MR readers (kappa of 0.8 for femoral head cartilage and 0.7 for acetabular cartilage).\nCONCLUSIONS: This study shows that noncontrast MRI of the hip, using an optimized protocol, can noninvasively identify labral and chondral pathology. Such information may facilitate deciding which patients warrant surgical intervention, thus preserving hip arthroscopy as a therapeutic tool.\nLEVEL OF EVIDENCE: Level II, Development of Diagnostic Criteria Study.', 'publication': 'Arthroscopy'}, {'PMID': 17114529, 'Study Quality': '2', 'title': 'MRI findings of femoroacetabular impingement.', 'abstract': 'OBJECTIVE: The purpose of our study was to evaluate MRI in the identification of labral and articular cartilage lesions in patients with a clinical suspicion of femoroacetabular impingement.\nMATERIALS AND METHODS: Preoperative MRI was performed in 46 consecutive patients (26 men, 20 women; age range, 21-45 years; mean age, 32.3 years) for whom femoroacetabular impingement was clinically suspected. Two musculoskeletal radiologists independently assessed the MR images for the presence and anatomic site of labral disorders, labral-chondral transitional zone disorders, femoral cartilage lesions, and acetabular cartilage lesions. Surgical correlation was obtained in all cases by two surgeons who were experienced in hip arthroscopy.\nRESULTS: Seven patients showed labral tears on MRI that were confirmed surgically in all cases. Thirty-seven patients (97%) of the 38 surgically confirmed cases had lesions of the labral-chondral transitional zone on MRI. The sites of labral-chondral transitional zone abnormalities at arthroscopy were 50% anterosuperior, 36% anterosuperior and superolateral, 11% superolateral, and 3% superolateral and posterosuperior. The site was identified correctly in 92% (reviewer 1) and 95% (reviewer 2) of cases on MRI. Separate acetabular cartilage abnormality was surgically identified in 39% of cases, and femoral cartilage lesions were found in 20%. The acetabular chondral lesions were correctly identified in 89-94% of cases.\nCONCLUSION: MRI provides a useful assessment of patients in whom a femoroacetabular impingement is clinically suspected. A high-resolution, nonarthrographic technique can provide preoperative information regarding the presence and anatomic site of labral and cartilage abnormalities.', 'publication': 'AJR Am J Roentgenol'}, {'PMID': 16530635, 'Study Quality': '4', 'title': 'Musculoskeletal imaging at 3T: current techniques and future applications.', 'abstract': 'MSK MR imaging applications are making the transition rapidly from 1.5T to 3T. Initial experience in the knee suggests that the higher SNR provides technical improvement in routine clinical imaging with the potential for greater accuracy in the diagnosis of articular cartilage injury. Similarly, initial experience with 3T MR imaging in the evaluation of the hip and small joints of the hand and wrist has been positive. In other joints, clinical development has been limited by the lack of availability of dedicated surface coils, and sensitivity of 3TMR imaging to artifact. The clinical impact of this technology remains uncertain because no published controlled clinical trial has evaluated the impact of 3T MR imaging on diagnostic outcomes. In addition to clinical application, 3T MR imaging has an important role for furthering translational research in MSK diseases through the development of new molecular and functional MR imaging techniques.', 'publication': 'Magn Reson Imaging Clin N Am'}, {'PMID': 16530634, 'Study Quality': '4', 'title': '3T MR imaging of the musculoskeletal system (Part II): clinical applications.', 'abstract': "The gain in SNR that is afforded by 3T MR imaging systems has tremendous clinical applications in the musculoskeletal system. The potential for demonstrating and enhancing the visibility of normal osseous, tendinous, cartilaginous, and ligamentous structures is exciting. Furthermore, harnessing this added signal to increase spatial resolution may improve our diagnostic abilities in various joints dramatically. Radiologists have enjoyed great success in assessing joint disease with current MR imaging field strengths; however, many intrinsic joint structures remain poorly evaluated, which leads to a golden opportunity for 3T MR imaging. The articular cartilage of the knee, the glenoid labrum of the shoulder, the intrinsic ligaments and TFC of the wrist, the collateral ligaments of the elbow, the labrum and articular cartilage of the hip, and the collateral ligaments of the ankle have been evaluated suboptimally on 1 .5T systems using routine nonarthrographic MR images. Because of the enhanced SNR, the higher spatial resolution, and the greater CNR of intrinsic joint structures at higher field strengths, 3T MR imaging has the potential to improve diagnostic abilities in the musculoskeletal system vastly, which translates into better patient care and management. The author's 2 years of clinical experience with musculoskeletal MR imaging on 3T systems has met and exceeded his expectations, and has bolstered the confidence of his orthopedic surgeons in his diagnoses. As coil technology advances and as the use of parallel imaging becomes more available in the extremities, the author expects to see even more dramatic improvements in image quality.", 'publication': 'Magn Reson Imaging Clin N Am'}, {'PMID': 22907475, 'Study Quality': '2', 'title': 'Anterior delayed gadolinium-enhanced MRI of cartilage values predict joint failure after periacetabular osteotomy.', 'abstract': 'BACKGROUND: Several available compositional MRIs seem to detect early osteoarthritis before radiographic appearance. Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) has been most frequently used in clinical studies and reportedly predicts premature joint failure in patients undergoing Bernese periacetabular osteotomies (PAOs).\nQUESTIONS/PURPOSES: We asked, given regional variations in biochemical composition in dysplastic hips, whether the dGEMRIC index of the anterior joint would better predict premature joint failure after PAOs than the coronal dGEMRIC index as previously reported.\nMETHODS: We retrospectively reviewed 43 hips in 41 patients who underwent Bernese PAO for hip dysplasia. Thirty-seven hips had preserved joints after PAOs and six were deemed premature failures based on pain, joint space narrowing, or subsequent THA. We used dGEMRIC to determine regional variations in biochemical composition. Preoperative demographic and clinical outcome score, radiographic measures of osteoarthritis and severity of dysplasia, and dGEMRIC indexes from different hip regions were analyzed in a multivariable regression analysis to determine the best predictor of premature joint failure. Minimum followup was 24 months (mean, 32 months; range, 24-46 months).\nRESULTS: The two cohorts were similar in age and sex distribution. Severity of dysplasia was similar as measured by lateral center-edge, anterior center-edge, and Tönnis angles. Preoperative pain, joint space width, Tönnis grade, and coronal and sagittal dGEMRIC indexes differed between groups. The dGEMRIC index in the anterior weightbearing region of the hip was lower in the prematurely failed group and was the best predictor.\nCONCLUSIONS: Success of PAO depends on the amount of preoperative osteoarthritis. These degenerative changes are seen most commonly in the anterior joint. The dGEMRIC index of the anterior joint may better predict premature joint failure than radiographic measures of hip osteoarthritis and coronal dGEMRIC index.\nLEVEL OF EVIDENCE: Level II, prognostic study. See Instructions for Authors for a complete description of levels of evidence.', 'publication': 'Clin Orthop Relat Res'}, {'PMID': 22933489, 'Study Quality': '3', 'title': 'Can T1-rho MRI detect acetabular cartilage degeneration in femoroacetabular impingement?: a pilot study.', 'abstract': 'Advanced MRI cartilage imaging such as T(1)-rho (T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic radiological changes may provide prognostic information in the management of joint disease. This study aimed first to determine the normal T1ρ profile of cartilage within the hip, and secondly to identify any differences in T1ρ profile between the normal and symptomatic femoroacetabular impingement (FAI) hip. Ten patients with cam-type FAI (seven male and three female, mean age 35.9 years (28 to 48)) and ten control patients (four male and six female, mean age 30.6 years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation times for full thickness and each of the three equal cartilage thickness layers were calculated and compared between the groups. The mean T1ρ relaxation times for full cartilage thickness of control and FAI hips were similar (37.17 ms (SD 9.95) and 36.71 ms (SD 6.72), respectively). The control group demonstrated a T1ρ value trend, increasing from deep to superficial cartilage layers, with the middle third having significantly greater T1ρ relaxation values than the deepest third (p = 0.008). The FAI group demonstrated loss of this trend. The deepest third in the FAI group demonstrated greater T1ρ relaxation values than controls (p = 0.028). These results suggest that 1.5T T1ρ MRI can detect acetabular hyaline cartilage changes in patients with FAI.', 'publication': 'J Bone Joint Surg Br'}, {'PMID': 30048144, 'Study Quality': '3', 'title': 'Does 3DMR provide equivalent information as 3DCT for the pre-operative evaluation of adult Hip pain conditions of femoroacetabular impingement and Hip dysplasia?', 'abstract': "OBJECTIVE:: Femoroacetabular impingement (FAI) and hip dysplasia (HD) are frequently evaluated by isotropic CT (3DCT) for preoperative planning at the expense of radiation. The aim was to determine if isotropic MRI (3DMR) imaging can provide similar quantitative and qualitative morphological information as 3DCT.\nMETHODS:: 25 consecutive patients with a final diagnosis of FAI or HD were retrospectively selected from December 2016-December 2017. Two readers (R1, R2) performed quantitative angular measurements on 3DCT and 3DMR, blinded to the diagnosis and each other's measurements. 3DMR and 3DCT of the hips were qualitatively and independently evaluated by a radiologist (R3), surgeon (R4), and fellow (R5). Interobserver and intermodality comparisons were performed.\nRESULTS:: The ICC was good to excellent for all measurements between R1 and R2 (ICC:0.60-0.98) and the majority of intermodality measurements for R1 and R2. Average inter-reader and inter-modality PABAK showed good to excellent agreement for qualitative reads. On CT, all alpha angles (AA) were significantly lower in dysplasia patients than in cam patients (p < 0.05). All lateral center-edge angle (LCEA) were significantly lower in dysplasia than in cam patients (p < 0.05). On MR, AA at 12, 1, and 2 o'clock, and LCEA at center were significantly lower in dysplasia patients than in cam patients (p < 0.05).\nCONCLUSION:: 3DMR offers similar qualitative and quantitative analysis as 3DCT in adult painful hip conditions.\nADVANCES IN KNOWLEDGE:: 3DMR has good potential to replace 3DCT and serve as a one-stop modality for bone and soft tissue characterizations in the pre-operative evaluation of FAI and HD.", 'publication': 'Br J Radiol'}, {'PMID': 31633993, 'Study Quality': '2', 'title': 'Evaluation of Osseous Morphology of the Hip Using Zero Echo Time Magnetic Resonance Imaging.', 'abstract': 'BACKGROUND: Femoroacetabular impingement syndrome (FAIS) is a common disorder of the hip resulting in groin pain and ultimately osteoarthritis. Radiologic assessment of FAI morphologies, which may present with overlapping radiologic features of hip dysplasia, often requires the use of computed tomography (CT) for evaluation of osseous abnormality, owing to the difficulty of direct visualization of cortical and subchondral bone with conventional magnetic resonance imaging (MRI). The use of a zero echo time (ZTE) MRI pulse sequence may obviate the need for CT by rendering bone directly from MRI.\nPURPOSE/HYPOTHESIS: The purpose was to explore the application of ZTE MRI to the assessment of osseous FAI and dysplasia morphologies of the hip. It was hypothesized that angular measurements from ZTE images would show significant agreement with measurements obtained from CT images.\nSTUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2.\nMETHODS: Thirty-eight hips from 23 patients were imaged with ZTE MRI and CT. Clinically relevant angular measurements of hip morphology were made in both modalities and compared to assess agreement. Measurements included coronal and sagittal center-edge angles, femoral neck-shaft angle, acetabular version (at 1-, 2-, and 3-o\'clock positions), Tönnis angle, alpha angle, and modified-beta angle. Interrater agreement was assessed for a subset of 10 hips by 2 raters. Intermodal agreement was assessed on the complete cohort and a single rater.\nRESULTS: Interrater agreement was demonstrated in both CT and ZTE, with intraclass correlation coefficient values ranging from 0.636 to 0.990 for ZTE and 0.747 to 0.983 for CT, indicating "good" to "excellent" agreement. Intermodal agreement was also shown to be significant, with intraclass correlation coefficients ranging from 0.618 to 0.904.\nCONCLUSION: Significant agreement of angular measurements for hip morphology exists between ZTE MRI and CT imaging. ZTE MRI may be an effective method to quantitatively evaluate osseous hip morphology.', 'publication': 'Am J Sports Med'}, {'PMID': 23395032, 'Study Quality': '4', 'title': 'Patient selection for rotational pelvic osteotomy.', 'abstract': 'Acetabular dysplasia is a common cause of hip pain and can lead to premature osteoarthritis. Preserving the native hip is the first choice in young, active patients with minimal arthrosis. Techniques in rotational pelvic osteotomy have evolved to offer long-term benefits, but appropriate patient selection is an important determinant of success. Applying a stepwise approach when evaluating adult patients with acetabular dysplasia and understanding current outcomes and predictive data will allow the orthopaedic surgeon to choose appropriate candidates for pelvic osteotomy.', 'publication': 'Instr Course Lect'}, {'PMID': 22985733, 'Study Quality': '2', 'title': 'Anterior inferior iliac spine deformity as an extra-articular source for hip impingement: a series of 10 patients treated with arthroscopic decompression.', 'abstract': 'PURPOSE: To describe an arthroscopic technique for decompression of a prominent anterior inferior iliac spine (AIIS) leading to extra-articular hip impingement and to provide short-term outcome after this procedure.\nMETHODS: We retrospectively reviewed office charts, imaging studies, operative reports, arthroscopic images, preoperative and postoperative hip flexion range of motion, and preoperative and postoperative modified Harris Hip Scores in a consecutive series of 10 male patients who had arthroscopic decompression of symptomatic AIIS deformities leading to extra-articular hip impingement. The procedure was performed through standard anterolateral and mid-anterior hip arthroscopy portals that were also used to explore the joint and address concomitant intra-articular pathologies.\nRESULTS: The mean age was 24.9 years, with 8 of 10 patients aged younger than 30 years. In 9 patients, an anterior cam lesion was identified and decompressed before the AIIS decompression. The mean follow-up time was 14.7 months (range, 6 to 26 months). Hip flexion range of motion improved from 99° ± 7° before surgery to 117° ± 8° after surgery (P < .001). The modified Harris Hip Score improved from 64 ± 18 before surgery to 98 ± 2 at latest follow-up after surgery (P < .001).\nCONCLUSIONS: Arthroscopic decompression of a symptomatic AIIS deformity is a reproducible procedure that can provide excellent outcomes at short-term follow-up. As opposed to using an open approach for decompressing a prominent AIIS, an arthroscopic approach may be of particular value in patients with mixed intra- and extra-articular sources of hip dysfunction, because it enables the surgeon to address all pathologies with a single arthroscopic procedure.\nLEVEL OF EVIDENCE: Level IV, therapeutic case series.', 'publication': 'Arthroscopy'}, {'PMID': 16721954, 'Study Quality': '4', 'title': 'The other hip in unilateral hip dysplasia.', 'abstract': 'UNLABELLED: We reviewed transverse pelvic computed tomography scans of 197 consecutively referred adult patients with hip pain thought to be secondary to developmental dysplasia. A center-edge angle of 20 degrees or less was considered the upper normal value. Four groups were identified: 69 patients with apparently unilateral right developmental dysplasia (left hip center-edge angles greater than 20 degrees), 26 patients with apparently unilateral left developmental dysplasia (right hip center-edge angles greater than 20 degrees), 68 patients with bilateral developmental dysplasia, and 34 patients with bilateral borderline developmental dysplasia (bilateral center-edge angles less than or equal to 25 degrees). The pelvic computed tomography scans were compared with computed tomography scans of 41 control subjects with healthy hips. The joint anatomy of patients with developmental dysplasia differed from that of control subjects in almost all aspects. Acetabular anteversion was larger in control subjects compared with patients with developmental dysplasia. We found inverse relationships between femoral anteversion and the anterior acetabular sector angle and coronal and sagittal center-edge angles in dysplastic hips, and also between femoral neck-shaft angles and the anterior acetabular sector angle. There was an inverse relationship between reduced anterior support developmental dysplasia in which plain radiographs suggested unilateral dysplastic abnormality only, computed tomography scans revealed both hips to be abnormal. The data suggest that patients referred with seemingly unilateral developmental dysplasia also are at risk of having contralateral dysplastic malformation.\nLEVEL OF EVIDENCE: Diagnostic study, Level II (development of diagnostic criteria on consecutive patients [with universally applied reference "gold" standard]). See the Guidelines for Authors for a complete description of levels of evidence.', 'publication': 'Clin Orthop Relat Res'}, {'PMID': 16211385, 'Study Quality': '4', 'title': 'Degeneration in dysplastic hips. A computer tomography study.', 'abstract': 'BACKGROUND: Hip dysplasia is considered pre-osteoarthritic, causing degeneration in young individuals.\nOBJECTIVE: To determine the pattern of degenerative change in moderate to severely dysplastic hips in young patients.\nDESIGN AND PATIENTS: One hundred and ninety-three consecutively-referred younger patients with hip pain believed to be caused by hip dysplasia constituted the study cohort. The average age was 35.5 years (range, 15-61 years). They were examined by close-cut transverse pelvic and knee computed tomography and antero-posterior radiographs (CT). We identified 197 hips with moderate to severe dysplasia, and 78 hips with normal morphology in the study cohort, whilst 111 hip joints were borderline dysplastic according to preset definitions. Comparative analyses of anatomy and distribution of degeneration between dysplastic and normal hips in the study cohort were performed.\nRESULTS: In dysplastic hips the anterior acetabular sector angle was significantly and inversely associated to femoral anteversion (p < 0.001). The center-edge (CE) angle, the acetabular angle (AA), and the acetabular depth ratio (ADR) were significantly interrelated (p < 0.001; correlation coefficients ranging from -0.8 to 0.7). Fifty-one hips were subluxated (24R/27L). There were no cases of complete dislocation. The formation of subchondral cysts or osteophytes in dysplastic hips was significantly associated with reduced minimum joint space width (p ranging from 0.005 to 0.02). However, in 67 hips with acetabular cysts, only 6 hips had minimum joint space widths = 2.0 mm (8.9%) in the coronal plane. In 96 cases with acetabular cysts found in the sagittal plane, 43 cases had minimum joint space widths = 2.0 mm (44.7%). Bony rim detachment at the site of labral insertion was recorded in 30 hips. Twenty-three of these were dysplastic (p = 0.01).\nCONCLUSIONS: Degeneration was most often found in the anterolateral part of the dysplastic hip joints. Most cysts were located above the transition zone between the bony and the fibrocartilaginous acetabulum, and we found a significantly- increased number of cases with avulsed bony fragments at the antero-lateral labral insertion in dysplastic hips compared to normal hips. It seems likely that the early degenerative process in dysplastic hips originates at the watershed zone between the acetabular labrum and the acetabular cartilage in response to subluxation and femoroacetabular impingement.', 'publication': 'Skeletal Radiol'}, {'PMID': 22492172, 'Study Quality': '4', 'title': 'LCPD: reduced range of motion resulting from extra- and intraarticular impingement.', 'abstract': 'BACKGROUND: Legg-Calvé-Perthes disease (LCPD) often results in a deformity that can be considered as a complex form of femoroacetabular impingement (FAI). Improved preoperative characterization of the FAI problem based on a noninvasive three-dimensional computer analysis may help to plan the appropriate operative treatment.\nQUESTIONS/PURPOSES: We asked whether the location of impingement zones, the presence of additional extraarticular impingement, and the resulting ROM differ between hips with LCPD and normal hips or hips with FAI.\nMETHODS: We used a CT-based virtual dynamic motion analysis based on a motion algorithm to simulate the individual motion for 13 hips with LCPD, 22 hips with FAI, and 27 normal hips. We then determined the motion and impingement pattern of each hip for the anterior (flexion, adduction, internal rotation) and the posterior impingement tests (extension, adduction, external rotation).\nRESULTS: The location of impingement zones in hips with LCPD differed compared with the FAI/normal groups. Intra- and extraarticular impingement was more frequent in LCPD (79% and 86%, respectively) compared with normal (15%, 15%) and FAI hips (36%, 14%). Hips with LCPD had decreased amplitude for all hip motions (flexion, extension, abduction, adduction, internal and external rotation) compared with FAI or normal.\nCONCLUSIONS: Hips with LCPD show a decreased ROM as a result of a higher prevalence of intra- and extraarticular FAI. Noninvasive assessment of impingement characteristics in hips with LCPD may be helpful in the future for establishment of a surgical plan.', 'publication': 'Clin Orthop Relat Res'}, {'PMID': 25558377, 'Study Quality': '3', 'title': 'Bony abnormalities of the hip joint: a new comprehensive, reliable and radiation-free measurement method using magnetic resonance imaging.', 'abstract': "OBJECTIVES: To develop comprehensive and reliable radiation-free methods to quantify femoral and acetabular morphology using MRI.\nMETHODS: 32 hips (16 subjects, 6 with intra-articular hip disorder (IAHD); 10 controls) were included. A 1.5T magnetic resonance system was used to obtain 3D fat suppressed gradient echo images at the pelvis and distal femora. After acquisition, pelvic images were post-processed to correct for coronal, axial and sagittal rotation. Measurements performed included acetabular version (AV), femoral version (FV), lateral center edge angle (LCEA), femoral neck angle (FNA) and alpha angle (AA) at 3, 2, 1 and 12 o'clock. Two experienced raters, a musculoskeletal radiologist and an orthopaedic physical therapist, and a novice rater, a research assistant, completed reliability testing. Raters measured all hips twice with minimum 2 weeks between sessions. Intraclass Correlation Coefficients were used to determine rater reliability; standard error of measurements was reported to estimate the reasonable limits of the expected error in the different raters' scores.\nRESULTS: Interrater reliability was good to excellent for all raters for AV, FV, FNA, and LCEA (ICCs: 0.82-0.98); good to excellent between experienced raters (ICCs: 0.78-0.86) and poor to good between novice and experienced raters (ICCs: 0.23-0.78) for AA. Intrarater reliability was good to excellent for all raters for AV, FV and FNA (ICCs: 0.93-0.99); for one experienced and novice rater for LCEA (ICCs: 0.84-0.89); moderate to excellent for the experienced raters for AA (ICCs: 0.72-0.89). Intrarater reliability was poor for the second experienced rater for LCEA (ICC: 0.56), due to a single measurement error and for the novice rater for AA (ICCs: 0.17-0.38).\nCONCLUSION: We described MRI methods to comprehensively assess femoral and acetabular morphology. Measurements such as AV, FV and FNA and the LCEA can be made reliably by both experienced and novice raters, however the AA measurement was reliable only among experienced raters.", 'publication': 'J Hip Preserv Surg'}, {'PMID': 18984718, 'Study Quality': '4', 'title': 'A systematic approach to the plain radiographic evaluation of the young adult hip.', 'abstract': None, 'publication': 'J Bone Joint Surg Am'}]
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strong
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usually not appropriate
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may be appropriate (disagreement)
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usually appropriate
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may be appropriate
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C
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Analyze the appropriateness of providing a Radiography chest on a patient with the following characteristics: known or suspected infective endocarditis. Additional imaging to direct patient management or treatment.
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may be appropriate
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[{'PMID': 6519077, 'Study Quality': '2', 'title': 'Prosthetic valve endocarditis: clinical findings and management.', 'abstract': 'Prosthetic valve endocarditis (PVE) was shown in 46 patients out of a group of 2163 carrying prosthetic heart valves. The cumulative rate of early PVE was 1.4% and 1.5% for PVE occurring between the 60th day and 10 years after surgery. In 37% of all cases this was caused by staphylococci, 20% by streptococci, and 13% Gram negative species. Fungi were found in 9% and mixed infections in 21%. The incidence of staphylococci, Gram negative pathogens and fungi was significantly higher in early PVE. In 5 patients, valve involvement consisted in echocardiographically shown vegetations and/or obstructive thromboendocarditis. In 90% of 37 patients who developed paravalvular leakages, there was high intravascular haemolysis uncharacteristic of the type of prosthesis implanted. In 70% fluoroscopy revealed disproportionate tilting of the prosthetic annulus, and in 75% there was a distinct echocardiographic pattern in the closing movement of the valve poppet. The cumulative survival rate after six months was 31% for the conservatively treated, and 66% for the medically plus surgically treated patients. Survival rates at the end of a maximum follow-up of 20 years was 15% with conservative treatment and 51% after primary surgical therapy. The prognosis was worse (P less than 0.01) in patients who, during aortic PVE, developed heart failure refractant to therapy due to haemodynamically significant prosthetic valve dysfunction, to sepsis that persisted for more than 72 h despite antibiotic therapy, to major septic embolism or to acute renal failure. The retrospective prognosis was more favourable for patients with early aortic (P less than 0.02) or mitral (P less than 0.05) valve re-replacement than for patients who had been treated medically only.', 'publication': 'Eur Heart J'}]
|
expert consensus
|
may be appropriate
|
usually not appropriate
|
may be appropriate (disagreement)
|
usually appropriate
|
A
|
Consider the appropriateness of providing a Magnetic Resonance Angiography head without Intravenous contrast on a patient with the following characteristics: child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
|
usually appropriate
|
[{'PMID': 25063989, 'Study Quality': '3'}]
|
expert consensus
|
usually appropriate
|
usually not appropriate
|
may be appropriate
|
may be appropriate (disagreement)
|
A
|
Consider the appropriateness of undertaking a Image-guided core biopsy breast on a patient with the following characteristics: adult female, 40 years of age or older. Palpable breast mass. Mammography findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study.
|
usually not appropriate
|
[{'PMID': 17924407, 'Study Quality': '3', 'title': 'A comparative analysis of core needle biopsy and fine-needle aspiration cytology in the evaluation of palpable and mammographically detected suspicious breast lesions.', 'abstract': 'The present study was undertaken to compare the efficacy of needle core biopsy (NCB) of the breast with fine-needle aspiration cytology (FNAC) in breast lesions (palpable and non-palpable) in the Indian set-up, along with the assessment of tumor grading with both the techniques. Fifty patients with suspicious breast lesions were subjected to simultaneous FNAC and ultrasound-guided NCB following an initial mammographic evaluation. Cases were categorized into benign, benign with atypia, suspicious and malignant groups. In cases of infiltrating duct carcinomas, grading was performed on cytological smears as well as on NCB specimens. Both the techniques were compared, and findings were correlated with radiological and excision findings. Out of 50 cases, 18 were found to be benign and 32 malignant on final pathological diagnosis. Maximum number of patients with benign diagnosis was in the fourth decade (42.11%) and malignant diagnosis in the fourth as well as fifth decade (35.48% each). Sensitivity and specificity of mammography for the diagnosis of malignancy was 84.37% and 83.33%, respectively. Sensitivity and specificity of FNAC for malignant diagnosis was 78.15% and 94.44%, respectively, and of NCB was 96.5% and 100%, respectively. But NCB had a slightly higher specimen inadequacy rate (8%). NCB improved diagnostic categorization over FNAC by 18%. Tumor grading in cases of IDC showed high concordance rate between NCB and subsequent excision biopsy (94.44%) but low concordance rate between NCB and FNAC (59.1%). NCB is superior to FNAC in the diagnosis of breast lesions in terms of sensitivity, specificity, correct histological categorization of the lesions as well as tumor grading.', 'publication': 'Diagn Cytopathol'}, {'PMID': -3098656, 'Study Quality': '4', 'title': '[Peripheral retinal dystrophy following administration of canthaxanthin?].', 'abstract': None, 'publication': 'Fortschr Ophthalmol'}, {'PMID': 23252555, 'Study Quality': '4', 'title': 'Stereotactic vacuum-assisted biopsies on a digital breast 3D-tomosynthesis system.', 'abstract': 'The purpose of this study was to describe our operating process and to report results of 118 stereotactic vacuum-assisted biopsies performed on a digital breast 3D-tomosynthesis system. From October 2009 to December 2010, 118 stereotactic vacuum assisted biopsies have been performed on a digital breast 3D-tomosynthesis system. Informed consent was obtained for all patients. A total of 106 patients had a lesion, six had two lesions. Sixty-one lesions were clusters of micro-calcifications, 54 were masses and three were architectural distortions. Patients were in lateral decubitus position to allow shortest skin-target approach (or sitting). Specific compression paddle, adapted on the system, performed, and graduated, allowing localization in X-Y. Tomosynthesis views define the depth of lesion. Graduated Coaxial localization kit determines the beginning of the biopsy window. Biopsies were performed with an ATEC-Suros, 9 Gauge handpiece. All biopsies, except one, have reached the lesions. Five hemorrhages were incurred in the process, but no interruption was needed. Eight breast hematomas, were all spontaneously resolved. One was an infection. About 40% of patients had a skin ecchymosis. Processing is fast, easy, and requires lower irradiation dose than with classical stereotactic biopsies. Histology analysis reported 45 benign clusters of micro-calcifications, 16 malignant clusters of micro-calcifications, 24 benign masses, and 33 malignant masses. Of 13 malignant lesions, digital 2D-mammography failed to detect eight lesions and underestimated the classification of five lesions. Digital breast 3D-tomosynthesis depicts malignant lesions not visualized on digital 2D-mammography. Development of tomosynthesis biopsy unit integrated to stereotactic system will permit histology analysis for suspicious lesions.', 'publication': 'Breast J'}, {'PMID': 25386875, 'Study Quality': '3', 'title': 'Digital breast tomosynthesis-guided vacuum-assisted breast biopsy: initial experiences and comparison with prone stereotactic vacuum-assisted biopsy.', 'abstract': 'PURPOSE: To use digital breast tomosynthesis (DBT)-guided vacuum-assisted biopsy (VAB) to sample target lesions identified at full-field digital screening mammography and compare clinical performance with that of prone stereotactic (PS) VAB.\nMATERIALS AND METHODS: In this institutional review board-approved study, 205 patients with 216 mammographic findings suspicious for cancer were scheduled to undergo mammography-guided VAB. Written informed consent was obtained. PS VAB was performed in 159 patients with 165 target lesions. DBT VAB was performed in 46 consecutive patients with 51 target lesions. Tissue-sampling methods and materials (9-gauge needles) were the same with both systems. For calcifications, specimen radiographs were obtained, and for masses or architectural distortions, control mammography or DBT was performed to confirm adequate target lesion sampling. χ(2) and Student t tests were used to compare biopsy time, and the Fisher exact test was used to compare lesion type distribution for DBT versus PS VAB.\nRESULTS: Technical success was achieved in 51 of 51 lesions (100%) with DBT VAB versus 154 of 165 lesions (93%) with PS VAB. In one of 11 lesions in which PS VAB failed, DBT VAB was performed successfully. Mean time to complete VAB was 13 minutes ± 3.7 for DBT VAB versus 29 minutes ± 10.1 for PS VAB (P < .0001). Reidentifying and targeting lesions during PS VAB took longer than it did during DBT VAB (P < .0001). Tissue sampling took about the same time for PS VAB and DBT VAB (P = .067). Significantly more "low-contrast" (ie, uncalcified) target lesions were biopsied with DBT VAB (13 of 51 lesions) versus PS VAB (nine of 165 lesions) (P < .0002). No major complications were observed with either system. One patient who underwent DBT VAB in the sitting position and one patient who underwent PS VAB developed self-limiting vasovagal reactions.\nCONCLUSION: Clinical performance of DBT VAB was significantly superior to PS VAB. Because DBT VAB allows use of the full detector size for imaging and provides immediate lesion depth information without requiring triangulation, it facilitates target lesion reidentification and sampling of even low-contrast targets, such as uncalcified masses.', 'publication': 'Radiology'}]
|
limited
|
may be appropriate
|
usually not appropriate
|
usually appropriate
|
may be appropriate (disagreement)
|
B
|
Investigate the appropriateness of performing a Radiography abdomen and pelvis on a patient with the following characteristics: suspected deep pelvic hernia including obturator, sciatic, or perineal. Initial imaging.
|
usually not appropriate
|
[{'PMID': 22138700, 'Study Quality': '4'}, {'PMID': 24078001, 'Study Quality': '4'}, {'PMID': 26985818, 'Study Quality': '4'}]
|
not specified
|
usually not appropriate
|
may be appropriate
|
usually appropriate
|
may be appropriate (disagreement)
|
A
|
Examine the appropriateness of offering a Ultrasound area of interest on a patient with the following characteristics: child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. Initial imaging.
|
may be appropriate
|
[{'PMID': 26444594, 'Study Quality': '3'}]
|
expert consensus
|
may be appropriate
|
usually appropriate
|
may be appropriate (disagreement)
|
usually not appropriate
|
A
|
Analyze the appropriateness of providing a Computed Tomography abdomen without and with Intravenous contrast on a patient with the following characteristics: suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
|
may be appropriate (disagreement)
|
[{'PMID': 18203942, 'Study Quality': '4', 'title': 'Pyelonephritis: radiologic-pathologic review.', 'abstract': 'Urinary tract infections are the most common urologic disease in the United States and annually account for over 7 million office and 1 million emergency department visits. In adults, diagnosis of urinary tract infection is typically based on characteristic clinical features and abnormal laboratory values. Imaging is usually reserved for patients who do not respond to therapy and for those whose clinical presentation is either atypical or potentially life threatening. Urinary tract infection typically originates in the urinary bladder; when it migrates to the kidney or is seeded there hematogenously, a tubulointerstitial inflammatory reaction ensues, involving the renal pelvis and parenchyma. The condition is characterized as pyelonephritis. Complicated and uncomplicated pyelonephritis, xanthogranulomatous pyelonephritis, and tuberculosis are all urinary tract infections for which imaging evaluation adds diagnostic information important for patient care. Computed tomography (CT), when performed before, immediately after, and at delayed intervals from contrast material injection, is the preferred modality for evaluating acute bacterial pyelonephritis. CT is also preferred over conventional radiography and ultrasonography (US) for assessing emphysematous pyelonephritis. Xanthogranulomatous pyelonephritis is a chronic granulomatous process, induced by recurrent bacterial urinary tract infection. Although US is useful in the diagnosis of this condition, CT is the main imaging tool, as it provides highly specific findings and accurate assessment of the extrarenal extent of disease, which is essential for surgical planning. The increasing prevalence of tuberculosis and continued emergence of antibiotic-resistant strains have significance for genitourinary radiologists, as the urinary tract is the most common extrapulmonary site of tuberculosis. Familiarity with the renal manifestations of the disease--pelvoinfundibular strictures, papillary necrosis, cortical low-attenuation masses, scarring, and calcification--will help in the diagnosis, even in the absence of documented pulmonary disease.', 'publication': 'Radiographics'}, {'PMID': 2655002, 'Study Quality': '4', 'title': 'Bacterial renal infection: role of CT.', 'abstract': 'The imaging studies done on 62 patients hospitalized for acute renal infections were retrospectively reviewed. Thirty-six (58%) had one or more abscesses, 17 (27%) had focal or diffuse acute bacterial nephritis, five (8%) had pyonephrosis, and four (6%) had pyelonephritis. All had prolonged fever (greater than or equal to 72 hours) and leukocytosis. Among 25 patients examined with both ultrasound (US) and computed tomography (CT), US failed to depict three of five (60%) cases of acute bacterial nephritis and seven of 15 (47%) intrarenal and extrarenal abscesses. One renal abscess was misdiagnosed as a tumor at CT. US is not an adequate screening test for detecting lesions that may require invasive therapy. CT is more sensitive for the detection of acute renal inflammatory disease and for defining the extent of disease for planning of radiologic or surgical intervention.', 'publication': 'Radiology'}, {'PMID': 7789019, 'Study Quality': '4', 'title': 'Delayed CT findings in acute renal infection.', 'abstract': 'The computed tomography (CT) findings in twelve patients with acute renal infection examined immediately and 3 h after i.v. contrast medium are reported. Three patients also had delayed scans at 6 h. Three main features were observed on the delayed scans: 1 a delayed nephrogram with streaky, wedge shaped or round high density areas. The areas of high density were at the same sites of the inhomogeneous areas of reduced density on the early scans; 2 focal contrast medium staining or a rim of increased density around abscesses; 3 focal areas of increased density at sites distant from the low density areas seen on the early scans. It is postulated that the delayed areas of increased density replace early areas of reduced density caused by ischemia due to vasospasm and/or compressing oedema of the vascular bed or by tubular obstruction. Delayed CT appears to be useful because it improves diagnostic confidence and gives a more exact evaluation of the extent of infection.', 'publication': 'Clin Radiol'}, {'PMID': 3883000, 'Study Quality': '4', 'title': 'Renal and perirenal infection: the role of computerized tomography.', 'abstract': "Predisposing factors, onset of symptoms to diagnosis interval, computerized tomography findings and the impact of computerized tomography on the outcome were studied retrospectively in 24 patients with renal or perirenal infections. The most common predisposing factors were diabetes mellitus and urinary tract calculi. The mean interval from the onset of symptoms to diagnosis was 6.8 days. The most common computerized tomography findings were thickening of Gerota's fascia, renal enlargement, focal decreased renal attenuation, perirenal fluid and focal gas. Four patients died despite early diagnosis and appropriate therapy. Computerized tomography aided in the diagnosis, assessment of the extent of disease, treatment and followup. Computerized tomography is the most direct method to evaluate patients with suspected renal or perirenal infection, although mortality may not be altered significantly.", 'publication': 'J Urol'}, {'PMID': 30392592, 'Study Quality': '4', 'title': 'ACR Appropriateness Criteria® Acute Pyelonephritis.', 'abstract': 'Pyelonephritis refers to infection involving the renal parenchyma and renal pelvis. In most patients, uncomplicated pyelonephritis is diagnosed clinically and responds quickly to appropriate antibiotic treatment. If treatment is delayed, the patient is immunocompromised, or for other reasons, microabscesses that form during the acute phase of pyelonephritis may coalesce, forming a renal abscess. Patients with underlying diabetes are more vulnerable to complications, including emphysematous pyelonephritis in addition to abscess formation. Additionally, diabetics may not have the typical flank tenderness that helps to differentiate pyelonephritis from a lower urinary tract infection. Additional high-risk populations may include those with anatomic abnormalities of the urinary tract, vesicoureteral reflux, obstruction, pregnancy, nosocomial infection, or infection by treatment-resistant pathogens. Treatment goals include symptom relief, elimination of infection to avoid renal damage, and identification of predisposing factors to avoid future recurrences. The primary imaging modalities used in patients with pyelonephritis are CT, MRI, and ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.', 'publication': 'J Am Coll Radiol'}, {'PMID': 28525662, 'Study Quality': '4', 'title': 'Imaging technologies in the diagnosis and treatment of acute pyelonephritis.', 'abstract': 'PURPOSE: The aim of this study was to evaluate the possibilities of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) in diagnosing acute pyelonephritis (AP) and renal abscess.\nPATIENTS AND METHODS: Two hundred and seven patients with AP were followed up from 2010 throughout 2015. All the patients were divided into three groups. Group 1 included 113 (54.6%) patients with acute nonobstructive pyelonephritis; group 2 included 33 (15.9%) patients with acute obstructive pyelonephritis; and group 3 included 61 (29.5%) pregnant female patients with AP.All 207 patients with AP underwent ultrasound examination of the kidneys. Computed tomography (CT) was performed in 87 patients (42.0%). MRI was performed in 14 patients (6.7%).\nRESULTS: We identified the ultrasound (US), magnetic resonance (MR), and CT-signs of acute renal inflammation at different stages of the process.The main us-signs were decreased mobility of the kidney, its enlargement, thickened parenchyma, hydrophilic parenchyma and an impairment of corticomedullary differentiation.The typical CT-signs of AP were enlargement of the kidney with its thickened parenchyma and an impairment of corticomedullary differentiation.The main MR-signs of AP were enlargement of the kidney (>12 cm lengthwise), thickened parenchyma (<2 cm in the median segment of the kidney) and an impairment of corticomedullary differentiation.\nCONCLUSIONS: Assessment of the structural and functional state of renal parenchyma and the upper urinary tract using techniques such as ultrasonography, CT, MRI contributes to more efficacious treatment of patients at different stages of AP and timely drainage with properly adjusted pathogenetic therapy at the infiltrative stage is instrumental in preventing purulent destructive forms of AP.', 'publication': 'Urologia'}, {'PMID': 30708379, 'Study Quality': '3', 'title': 'Imaging in Acute Pyelonephritis: Utilization, Findings, and Effect on Management.', 'abstract': 'OBJECTIVES: To determine the frequency, timing, and types of imaging obtained in patients with a discharge diagnosis of acute pyelonephritis, and how often imaging findings affect therapy.\nMETHODS: This was a retrospective chart review of 1062 adults with a diagnosis of acute pyelonephritis discharged from an urban, safety-net hospital between January 1, 2008 and December 31, 2012. From the 739 patients selected after exclusions, we determined the number and proportion of patients imaged within the first 24 hours of admission, stratified by risk factors for pyelonephritis complications, and the frequency of positive findings leading to invasive interventions.\nRESULTS: Of 739 patients, 468 (63%) were imaged within 24 hours of admission, 262/414 (63%) of whom had risk factors for complications and 206/325 of whom (63%) did not. Among these, studies were positive in 117/468 (25%), 78/262 (30%) in those with risk factors, and 39/206 (19%) of those without risk factors. Of the 117 patients with positive imaging findings within 24 hours of admission, 58 (50%) underwent invasive procedures, 47 (60%) with risk factors and 11 (28%) without. Among all of the patients, interventions were directed at relieving obstructions much more commonly than treating abscess (51 patients vs 8).\nCONCLUSIONS: Among this population, imaging is frequently done earlier than recommended. Because the majority of interventions targeted stone disease, ultrasound may be the preferred initial modality rather than contrasted tomography when obtaining imaging early. Current guidelines may need to be revisited.', 'publication': 'South Med J'}, {'PMID': 30224907, 'Study Quality': '3', 'title': 'Clinical Usefulness of Unenhanced Computed Tomography in Patients with Acute Pyelonephritis.', 'abstract': 'BACKGROUND: Unenhanced computed tomography (UCT) may be useful for evaluating acute pyelonephritis; however, no study has compared UCT with enhanced computed tomography (ECT) as a diagnostic tool. We evaluated a clinical usefulness of UCT versus ECT in acute pyelonephritis (APN).\nMETHODS: We reviewed the clinical and radiological data from 183 APN-suspected patients who underwent UCT and ECT simultaneously at emergency room (ER) over a two-year period. Demographic, clinical parameters and computed tomography (CT) parameters of 149 patients were compared.\nRESULTS: The average patient age was 61.2 (± 10) years: 31 patients were men. Ninety-nine (66.4%) patients showed stones (18.7%), perinephric infiltration (56%), swelling (21%), and hydronephrosis (6.7%) on UCT. Seventeen patients (11.4%) had an atypical clinical course, requiring additional tests for accurate diagnosis. In 7 patients UCT and ECT results did not differ; in 10 patients, the diagnosis changed on ECT. On ECT, 112/149 (75.2%) patients had stones (16.7%), perinephric infiltrations (57%), swelling (21%), and hydronephrosis (6.7%); 62.5% showed parenchymal involvement: 34 (22.8%) patients had no abnormal ECT findings. APN CT findings are similar on stone, perinephric infiltration, swelling and hydronephrosis on both CTs. Twelve patients (8.0%) had an abnormal ECT finding, i.e., low-grade (1 and 2) parenchymal involvement. Six (4%) patients developed contrast-induced acute kidney injury within 2 days after ECT.\nCONCLUSION: We demonstrate that UCT is not inferior to ECT as an initial tool for evaluating APN for screening nephrolithiasis and hydronephrosis without the risk of contrast-induced acute kidney injury (CIAKI). However, patients with an atypical clinical course may still need ECT.', 'publication': 'J Korean Med Sci'}, {'PMID': 29298155, 'Study Quality': '4', 'title': 'Acute Pyelonephritis in Adults.', 'abstract': None, 'publication': 'N Engl J Med'}, {'PMID': 22859793, 'Study Quality': '4', 'title': 'Diagnosis of acute pyelonephritis with recent trends in management.', 'abstract': None, 'publication': 'Nephrol Dial Transplant'}]
|
expert opinion
|
may be appropriate
|
may be appropriate (disagreement)
|
usually appropriate
|
usually not appropriate
|
B
|
Survey the appropriateness of delivering a Computed Tomography chest with Intravenous contrast on a patient with the following characteristics: confirmed diffuse lung disease without acute clinical deterioration. Routine follow-up imaging clinically indicated.
|
may be appropriate
|
[{'PMID': 8153310, 'Study Quality': '2', 'title': 'Chronic diffuse infiltrative lung disease: determination of the diagnostic value of clinical data, chest radiography, and CT and Bayesian analysis.', 'abstract': 'PURPOSE: To assess the value of clinical, chest radiographic, and computed tomographic (CT) findings in classifying chronic diffuse infiltrative lung disease (CDILD) MATERIALS AND METHODS: Two samples from the same population were consecutively studied: the training set (group A, n = 208) for the development of the decision aid and the test set (group B, n = 100) for validation. Computer-aided diagnoses were made with a Bayesian model that assigned to each patient diagnostic probabilities based on clinical, radiographic, or CT variables.\nRESULTS: In group A, a correct diagnosis based on clinical data was obtained in 29% of cases; radiography, 9%; and CT, 36%. This increased to 54% when clinical and radiographic variables were combined (P < .0001) and to 80% when data from all three were analyzed together (P < .0001). With prior and conditional probabilities determined from group A, the frequency of correct diagnosis in group B was 27% with clinical data, which increased to 53% (P < .0001) with radiographic findings and 61% after including CT data (P = .07).\nCONCLUSION: CT can help determine the specific diagnosis in patients with CDILD.', 'publication': 'Radiology'}, {'PMID': 1535900, 'Study Quality': '4', 'title': 'High-resolution CT diagnosis of emphysema in symptomatic patients with normal chest radiographs and isolated low diffusing capacity.', 'abstract': 'To determine the prevalence of "nonobstructive" (impairment of gas transfer) emphysema in a select population of smokers with dyspnea, a retrospective study of patients with emphysema evident at high-resolution computed tomography (HRCT) was undertaken. Four hundred seventy HRCT studies were reviewed. In 47 cases, centrilobular emphysema was the dominant or sole parenchymal abnormality. Concomitant chest radiographs were available in 41 of these cases; 16 of the 41 lacked radiographic findings of emphysema. Among these 16 patients, pulmonary function testing revealed 10 to have normal flow rates (ratio of forced expiratory volume in 1 second to forced vital capacity and forced expiratory volume in 1 second greater than 80% predicted) and impaired gas transfer (single-breath carbon monoxide diffusing capacity [DLCOSB] less than 80% predicted). With the exclusion of one patient with congestive heart failure from the group of 10, the severity of emphysema at HRCT correlated inversely with DLCOSB (r = -.643). These results indicate that HRCT allows detection of emphysema in symptomatic patients when chest radiographs and pulmonary function tests are nondiagnostic.', 'publication': 'Radiology'}, {'PMID': 2717730, 'Study Quality': '2', 'title': 'Sarcoidosis: correlation of extent of disease at CT with clinical, functional, and radiographic findings.', 'abstract': 'Computed tomography (CT) was compared with chest radiography in the assessment of disease severity in 27 patients with sarcoidosis. The CT scans and radiographs were each read twice by two independent observers. Disease extent was assessed on CT scans by visual scoring (0%-100% involvement of the lung parenchyma) and on radiographs by using an adaptation of the International Labour Office classification. The severity of parenchymal changes on the CT scan and on the radiograph was significantly correlated with the severity of dyspnea (r = .61 and .58, respectively; P less than .001), diffusing capacity (r = -.62 and -.52, P less than .01), and vital capacity (r = -.49 and -.51, P less than .01). Patients with predominantly irregular opacities had more severe dyspnea and lower lung volumes than patients with predominantly nodular opacities (P less than .05). The authors conclude that in patients with sarcoidosis, the radiographic and CT assessments of disease severity show similar correlation with clinical and functional impairment.', 'publication': 'Radiology'}, {'PMID': 21926853, 'Study Quality': '3', 'title': 'Nonspecific interstitial pneumonia: prognostic significance of high-resolution computed tomography in 59 patients.', 'abstract': 'OBJECTIVE: To retrospectively analyze the prognostic implications of high-resolution computed tomography (HRCT) findings for patients with biopsy-proven nonspecific interstitial pneumonia (NSIP).\nMETHODS: Fifty-nine patients with NSIP (25 idiopathic NSIP, 34 collagen-vascular disease-associated NSIP) were included. Two chest radiologists independently evaluated the extent, presence, and distribution of various HRCT findings. Cox hazards analysis was used to evaluate the relationship between HRCT findings and prognosis.\nRESULTS: The 5-year survival rate was 83% and the 10-year survival rate was 66%. Univariate analysis revealed that the extent of areas with ground-glass attenuation without traction bronchi-bronchiolectasis and that of airs-pace consolidation were associated with favorable outcome, whereas that of intralobular reticular opacities was associated with worse prognosis. Multivariate analysis showed that the extent of air-space consolidation was an independent factor of favorable outcome.\nCONCLUSION: In NSIP, the extent of areas with ground-glass attenuation without traction bronchi-bronchiolectasis, air-space consolidation, and intralobular reticular opacities correlate with survival.', 'publication': 'J Comput Assist Tomogr'}, {'PMID': 20622689, 'Study Quality': '2', 'title': 'Longitudinal follow-up of fibrosing interstitial pneumonia: relationship between physiologic testing, computed tomography changes, and survival rate.', 'abstract': 'PURPOSE: The aim of this study was to evaluate the prognostic implications of computed tomography (CT) and physiologic variables at baseline and on sequential evaluation in patients with fibrosing interstitial pneumonia.\nMATERIALS AND METHODS: We identified 72 patients with fibrosing interstitial pneumonia (42 with idiopathic disease, 30 with collagen vascular disease). Pulmonary function tests and CT were performed at the time of diagnosis and at a median follow-up of 12 months, respectively. Two chest radiologists scored the extent of specific abnormalities and overall disease on baseline and follow-up CT. Rate of survival was estimated using the Kaplan-Meier method. Three Cox proportional hazards models were constructed to evaluate the relationship between CT and physiologic variables and rate of survival: model 1 included only baseline variables, model 2 included only serial change variables, and model 3 included both baseline and serial change variables.\nRESULTS: On follow-up CT, the extent of mixed ground-glass and reticular opacities (P<0.001), pure reticular opacity (P=0.04), honeycombing (P=0.02), and overall extent of disease (P<0.001) was increased in the idiopathic group, whereas these variables remained unchanged in the collagen vascular disease group. Patients with idiopathic disease had a shorter rate of survival than those with collagen vascular disease (P=0.03). In model 1, the extent of honeycombing on baseline CT was the only independent predictor of mortality (P=0.02). In model 2, progression in honeycombing was the only predictor of mortality (P=0.005). In model 3, baseline extent of honeycombing and progression of honeycombing were the only independent predictors of mortality (P=0.001 and 0.002, respectively). Neither baseline nor serial change physiologic variables, nor the presence of collagen vascular disease, was predictive of rate of survival.\nCONCLUSION: The extent of honeycombing at baseline and its progression on follow-up CT are important determinants of rate of survival in patients with fibrosing interstitial pneumonia.', 'publication': 'J Thorac Imaging'}, {'PMID': 25810444, 'Study Quality': '2'}, {'PMID': 23293132, 'Study Quality': '3'}, {'PMID': 24953093, 'Study Quality': '2'}, {'PMID': 24038345, 'Study Quality': '2'}, {'PMID': 23392130, 'Study Quality': '1'}, {'PMID': 21412103, 'Study Quality': '2'}, {'PMID': 19997848, 'Study Quality': '2'}, {'PMID': 26452110, 'Study Quality': '4'}, {'PMID': 25916462, 'Study Quality': '2'}, {'PMID': 2928513, 'Study Quality': '4'}, {'PMID': 2217770, 'Study Quality': '4'}, {'PMID': 2006262, 'Study Quality': '2'}, {'PMID': 1959296, 'Study Quality': '2'}, {'PMID': 30168753, 'Study Quality': '4'}, {'PMID': 29154106, 'Study Quality': '4'}, {'PMID': 23222877, 'Study Quality': '1'}, {'PMID': 25203455, 'Study Quality': '4'}, {'PMID': 25211168, 'Study Quality': '4'}, {'PMID': 27809901, 'Study Quality': '2'}, {'PMID': 27758993, 'Study Quality': '2'}, {'PMID': 26253261, 'Study Quality': '4'}, {'PMID': 28583621, 'Study Quality': '4'}, {'PMID': 28483105, 'Study Quality': '4'}, {'PMID': 27565631, 'Study Quality': '2'}, {'PMID': 30467322, 'Study Quality': '2'}, {'PMID': 30344228, 'Study Quality': '2'}, {'PMID': 15894598, 'Study Quality': '1'}, {'PMID': 24479411, 'Study Quality': '2'}, {'PMID': 21071764, 'Study Quality': '3'}, {'PMID': 15653982, 'Study Quality': '4'}, {'PMID': 9196515, 'Study Quality': '4'}, {'PMID': 27314401, 'Study Quality': '4'}, {'PMID': 9240543, 'Study Quality': '4'}, {'PMID': 24522562, 'Study Quality': '1'}, {'PMID': 22580808, 'Study Quality': '2'}, {'PMID': 8697837, 'Study Quality': '2'}, {'PMID': 16145289, 'Study Quality': '2'}, {'PMID': 22805187, 'Study Quality': '2'}, {'PMID': 25896472, 'Study Quality': '4'}, {'PMID': 10511155, 'Study Quality': '2'}, {'PMID': 22446354, 'Study Quality': '2'}, {'PMID': 10934089, 'Study Quality': '4'}, {'PMID': 23096169, 'Study Quality': '2'}, {'PMID': 20858818, 'Study Quality': '4'}, {'PMID': 1503008, 'Study Quality': '4'}, {'PMID': 12232448, 'Study Quality': '4'}, {'PMID': 17135233, 'Study Quality': '4'}, {'PMID': 10667656, 'Study Quality': '4'}, {'PMID': 15232373, 'Study Quality': '2'}, {'PMID': 21298694, 'Study Quality': '2'}, {'PMID': 8372179, 'Study Quality': '2'}, {'PMID': 15642299, 'Study Quality': '2'}, {'PMID': 18270375, 'Study Quality': '2'}, {'PMID': 20538446, 'Study Quality': '2'}, {'PMID': 27829068, 'Study Quality': '4'}, {'PMID': 32706311, 'Study Quality': '4'}]
|
strong
|
usually not appropriate
|
usually appropriate
|
may be appropriate (disagreement)
|
may be appropriate
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D
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Appraise the appropriateness of delivering a Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography skull base to mid-thigh on a patient with the following characteristics: nontraumatic chest wall pain. Suspected infectious or inflammatory condition. Secondary evaluation after normal chest radiograph. Next imaging study.
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may be appropriate
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[{'PMID': 25917543, 'Study Quality': '4'}, {'PMID': 30205705, 'Study Quality': 'Not Assessed'}, {'PMID': 23359660, 'Study Quality': '4'}, {'PMID': 17954662, 'Study Quality': '4'}]
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moderate
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usually appropriate
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may be appropriate (disagreement)
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may be appropriate
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usually not appropriate
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C
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Gauge the appropriateness of executing a Magnetic Resonance Imaging head without and with Intravenous contrast on a patient with the following characteristics: unilateral isolated weakness of the facial expression, paralysis of the facial expression, hemifacial spasm, or Bell palsy (facial nerve, CN VII). Initial imaging.
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usually appropriate
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[{'PMID': 22784861, 'Study Quality': '3', 'title': 'Clinical feasibility of temporal bone magnetic resonance imaging as a prognostic tool in idiopathic acute facial palsy.', 'abstract': 'OBJECTIVE: To assess the feasibility of temporal bone magnetic resonance imaging for evaluating the severity and prognosis of idiopathic acute facial nerve palsy.\nMETHODS: Forty-four patients with idiopathic acute facial nerve palsy who had undergone gadolinium-enhanced magnetic resonance imaging were selected retrospectively. The degree of radiological facial nerve enhancement was determined using quantitative analysis (with region-of-interest measurements for separate facial nerve segments) and using subjective visual analysis. The clinical severity of facial nerve palsy was then correlated with the degree of facial nerve enhancement.\nRESULTS: The visually determined degree of facial nerve enhancement did not correlate significantly with the House-Brackmann grade at either the early or late stages (p > 0.05). Results using the region-of-interest system were similar (p > 0.05).\nCONCLUSION: Temporal bone magnetic resonance imaging is not essential for patients with acute facial nerve palsy.', 'publication': 'J Laryngol Otol'}, {'PMID': 24518410, 'Study Quality': '4', 'title': "Differences in the diameter of facial nerve and facial canal in bell's palsy--a 3-dimensional temporal bone study.", 'abstract': "UNLABELLED: Bell's palsy is hypothesized to result from virally mediated neural edema. Ischemia occurs as the nerve swells in its bony canal, blocking neural blood supply. Because viral infection is relatively common and Bell's palsy relatively uncommon, it is reasonable to hypothesize that there are anatomic differences in facial canal (FC) that predispose the development of paralysis. Measurements of facial nerve (FN) and FC as it follows its tortuous course through the temporal bone are difficult without a 3D view. In this study, 3D reconstruction was used to compare temporal bones of patients with and without history of Bell's palsy.\nMETHODS: Twenty-two temporal bones (HTBs) were included in the study, 12 HTBs from patients with history of Bell's palsy and 10 healthy controls. Three-dimensional models were generated from HTB histopathologic slides with reconstruction software (Amira), diameters of the FC and FN were measured at the midpoint of each segment.\nRESULTS: The mean diameter of the FC and FN was significantly smaller in the tympanic and mastoid segments (p = 0.01) in the BP group than in the controls. The FN to FC diameter ratio (FN/FC) was significantly bigger in the mastoid segment of BP group, when compared with the controls. When comparing the BP and control groups, the narrowest part of FC was the labyrinthine segment in control group and the tympanic segment in the BP.\nCONCLUSION: This study suggests an anatomic difference in the diameter of FC in the tympanic and mastoid segments but not in the labyrinthine segment in patients with Bell's palsy.", 'publication': 'Otol Neurotol'}, {'PMID': 11960404, 'Study Quality': '2', 'title': "[The prognostic value of quantified MRI at an early stage of Bell's palsy].", 'abstract': "OBJECTIVE: The aim of the study was to assess whether MRI has a prognostic value at an early stage of Bell's palsy.\nMATERIAL AND METHODS: Prospective, blinded study on 30 patients suffering from Bell's palsy, who came to hospital until the sixth day of illness, to receive high doses steroid therapy. MRI was done on the first day of inpatient treatment as a gradient-echo-sequence with a slice thickness of 0.7 mm before and after i. v. administration of 0.1 mmol GdDTPA/kg weight. The signal intensity increase was evaluated quantitatively by region on interest (ROI). The results were compared to the clinical outcome and the results of electrophysiology.\nRESULTS: The examinations of all patients could be evaluated. The 3 patients who developed a chronic facial paralysis were detected by MRI on the first day of inpatient treatment. The patients, who showed MR signs for an unfavorable course, had a highly significant pathologic compound muscle action potential (CMAP) as a result of the electrophysiologic measurement. Rather than using complex measurement procedures it is possible to obtain reliable prognostic information from just one measurement within the Internal auditory canal before and after i. v. administration of contrast.\nCONCLUSION: MRI has a prognostic value at an early stage of the illness. In the clinical setting this measurement is easy to perform, so that it is possible to obtain prognostic information at a stage when causal treatment is still possible.", 'publication': 'Rofo'}, {'PMID': 14699179, 'Study Quality': '2', 'title': 'Bell palsy: quantitative analysis of MR imaging data as a method of predicting outcome.', 'abstract': 'PURPOSE: To assess the prognostic value of quantitative analyses of region-of-interest (ROI) magnetic resonance (MR) imaging data in patients with acute facial nerve palsy.\nMATERIALS AND METHODS: In a single-blinded study, MR images were obtained in 39 patients (32 men and seven women; age range, 18-75 years; average age, 37.9 years) with acute facial nerve palsy. MR images were obtained before the 6th day of illness, on the first day of standard inpatient treatment with high-dose steroids. Signal intensity (SI) was measured at ROIs in each of five segments (internal auditory canal [IAC]; geniculate ganglion; and labyrinth, tympanic, and mastoid segments) of the intratemporal portion of the facial nerve and quantitatively analyzed. The SI measurements in the five segments were summed and divided by 100 to provide a basis for establishing an MR imaging index. SI increases and MR imaging indexes were compared with available clinical findings and electrophysiologic data.\nRESULTS: Data for all 39 patients could be analyzed. The MR imaging index was significantly higher in patients with poor outcomes than in patients with favorable outcomes (specificity, 97%; sensitivity, 75%; P <.01). The SI increases in the IAC were significantly different between patients who progressed to full recovery (mean increase, 45.7%) and patients who developed chronic facial paralysis (mean increase, 156.5%) (sensitivity, 100%; specificity, 97%; P <.001). The results of differentiating between patients with good and those with poor outcomes on the basis of SI measurements in the IAC were found to be in complete agreement with electrophysiologic data.\nCONCLUSION: Quantitative analysis of ROI MR imaging data is a valid method of predicting the outcome of acute facial nerve palsy during the first days after onset of symptoms and thus at a time when it is not yet possible to obtain valuable prognostic information by using electrophysiologic methods.', 'publication': 'Radiology'}, {'PMID': 19546177, 'Study Quality': '4', 'title': 'Enhancement pattern of the normal facial nerve at 3.0 T temporal MRI.', 'abstract': "The purpose of this study was to evaluate the enhancement pattern of the normal facial nerve at 3.0 T temporal MRI. We reviewed the medical records of 20 patients and evaluated 40 clinically normal facial nerves demonstrated by 3.0 T temporal MRI. The grade of enhancement of the facial nerve was visually scaled from 0 to 3. The patients comprised 11 men and 9 women, and the mean age was 39.7 years. The reasons for the MRI were sudden hearing loss (11 patients), Méniàre's disease (6) and tinnitus (7). Temporal MR scans were obtained by fluid-attenuated inversion-recovery (FLAIR) and diffusion-weighted imaging of the brain; three-dimensional (3D) fast imaging employing steady-state acquisition (FIESTA) images of the temporal bone with a 0.77 mm thickness, and pre-contrast and contrast-enhanced 3D spoiled gradient record acquisition in the steady state (SPGR) of the temporal bone with a 1 mm thickness, were obtained with 3.0 T MR scanning. 40 nerves (100%) were visibly enhanced along at least one segment of the facial nerve. The enhanced segments included the geniculate ganglion (77.5%), tympanic segment (37.5%) and mastoid segment (100%). Even the facial nerve in the internal auditory canal (15%) and labyrinthine segments (5%) showed mild enhancement. The use of high-resolution, high signal-to-noise ratio (with 3 T MRI), thin-section contrast-enhanced 3D SPGR sequences showed enhancement of the normal facial nerve along the whole course of the nerve; however, only mild enhancement was observed in areas associated with acute neuritis, namely the canalicular and labyrinthine segment.", 'publication': 'Br J Radiol'}, {'PMID': 25795466, 'Study Quality': '2', 'title': 'Preoperative Evaluation of Patients with Hemifacial Spasm by Three-dimensional Time-of-Flight (3D-TOF) and Three-dimensional Constructive Interference in Steady State (3D-CISS) Sequence.', 'abstract': 'PURPOSE: The purpose of this study was to investigate and evaluate the accuracy and the preoperative diagnostic value of high-resolution magnetic resonance imaging (MRI) techniques, three-dimensional time-of-flight (3D-TOF) and three-dimensional constructive interference in steady state (3D-CISS) sequence, solely or in combination for the detection of the relationship between the facial nerve and adjacent vessels in patients with hemifacial spasm (HFS).\nMETHODS: A total of 95 patients with primary HFS were subject to 3D-TOF and 3D-CISS MRI. The MR images were then used to evaluate the anatomical neurovascular relationships, and the results were compared with the surgical findings. We categorized the neurovascular relationship into three types: compression, contact, and neighboring or distant. Compression and/or contacts between root exit zone (REZ) and vessels were defined as positive, whereas neighboring or distant was considered to be negative.\nRESULTS: 3D-TOF combined with 3D-CISS assessment showed that 94 of 95 patients had artery compression or contact at REZ, whereas the remaining patient had compression at the peripheral branch of the facial nerve but not at REZ. The positive rates and the overall accuracy were 98.95 and 100\u2009%, respectively, for the 3D-TOF combined with 3D-CISS assessment; 92.63 and 93.68\u2009%, respectively, for the 3D-TOF assessment; and 85.26 and 86.32\u2009%, respectively, for the 3D-CISS assessment. The positive rates and overall accuracy for the 3D-TOF combined with 3D-CISS assessment was significantly higher than those for the 3D-TOF or 3D-CISS assessment.\nCONCLUSIONS: Combination of 3D-TOF with 3D-CISS imaging well delineates the relationship between the facial nerve and adjacent vessels in terms of increased positive rates and accuracy.', 'publication': 'Clin Neuroradiol'}, {'PMID': 9576658, 'Study Quality': '2', 'title': 'Perineural spread of head and neck tumors: how accurate is MR imaging?', 'abstract': 'PURPOSE: Our aim was to determine the precision of MR imaging evaluation of perineural spread of head and neck tumors.\nMETHODS: Nineteen patients had complete extirpation of head and neck tumors (10 squamous cell carcinomas, four adenoid cystic carcinomas, one poorly differentiated carcinoma, one salivary duct carcinoma, one mucoepidermoid carcinoma, one chordoma, and one meningioma) with histologic confirmation of perineural spread. Findings at presurgical contrast-enhanced MR imaging were compared with findings at pathologic examination.\nRESULTS: The sensitivity of MR imaging for detection of perineural spread was 95%; however, the sensitivity for mapping the entire extent of perineural spread fell to 63%.\nCONCLUSION: MR imaging may fail to depict microscopic foci of perineural tumor infiltration, leading to underestimation of the extent of perineural spread. Nevertheless, with careful analysis of foraminal architecture and MR enhancement patterns, one can reliably identify the presence if not the extent of perineural spread.', 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 30717625, 'Study Quality': '2', 'title': 'Evaluating Perineural Spread to the Intratemporal Facial Nerve on Magnetic Resonance Imaging.', 'abstract': 'OBJECTIVES: To determine the sensitivity and specificity of magnetic resonance imaging (MRI) for the detection of perineural spread (PNS) along the intratemporal facial nerve (ITFN) in patients with head and neck cancers.\nSTUDY DESIGN: Case series with chart review.\nSETTING: Tertiary care center.\nSUBJECTS AND METHODS: We included 58 patients with head and neck malignancies who underwent sacrifice of the ITFN between August 1, 2002, and November 30, 2015. Demographics, preoperative facial nerve function, prior oncologic treatment, and timing between MRI and surgery were recorded. Histopathology slides and preoperative MRI were reviewed retrospectively by a neuropathologist and a neuroradiologist, respectively, both blinded to clinical data. The mastoid segment of the facial nerve (referred to as the descending facial nerve [DFN]) and stylomastoid foramen (SMF) were evaluated separately. A grading system was devised when radiographically assessing PNS along the DFN.\nRESULTS: Histopathologic evidence of PNS was found in 21 patients (36.2%). The sensitivity and specificity of MRI in detecting PNS to the DFN were 72.7% and 87.8%, respectively. MRI showed higher sensitivity but slightly lower specificity when evaluating the SMF (80% and 82.8%, respectively). Prior oncologic treatment did not affect the false-positive rate ( P = .7084). Sensitivity was 100% when MRI was performed within 2 weeks of surgery and was 62.5% to 73.3% when the interval was greater than 2 weeks. This finding was not statistically significant (SMF, P = .7076; DFN, P = .4143).\nCONCLUSION: MRI shows fair to good sensitivity and good specificity when evaluating PNS to the ITFN.', 'publication': 'Otolaryngol Head Neck Surg'}, {'PMID': 30139756, 'Study Quality': '4', 'title': 'MR Imaging of the Facial Nerve through the Temporal Bone at 3T with a Noncontrast Ultrashort Echo Time Sequence.', 'abstract': 'The pointwise encoding time reduction with radial acquisition (PETRA) ultrashort echo time MR imaging sequence at 3T enables visualization of the facial nerve from the brain stem, through the temporal bone, to the stylomastoid foramen without intravenous contrast. Use of the PETRA sequence, or other ultrashort echo time sequences, should be considered in the MR imaging evaluation of certain skull base tumors and perhaps other facial nerve and temporal bone pathologies.', 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 29490547, 'Study Quality': '4', 'title': 'Preoperative diffusion tensor imaging-fiber tracking for facial nerve identification in vestibular schwannoma: a systematic review on its evolution and current status with a pooled data analysis of surgical concordance rates.', 'abstract': 'OBJECTIVE Total tumor excision with the preservation of neurological function and quality of life is the goal of modern-day vestibular schwannoma (VS) surgery. Postoperative facial nerve (FN) paralysis is a devastating complication of VS surgery. Determining the course of the FN in relation to a VS preoperatively is invaluable to the neurosurgeon and is likely to enhance surgical safety with respect to FN function. Diffusion tensor imaging-fiber tracking (DTI-FT) technology is slowly gaining traction as a viable tool for preoperative FN visualization in patients with VS. METHODS A systematic review of the literature in the PubMed, Cochrane Library, and Web of Science databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and those studies that preoperatively localized the FN in relation to a VS using the DTI-FT technique and verified those preoperative FN tracking results by using microscopic observation and electrophysiological monitoring during microsurgery were included. A pooled analysis of studies was performed to calculate the surgical concordance rate (accuracy) of DTI-FT technology for FN localization. RESULTS Fourteen studies included 234 VS patients (male/female ratio 1:1.4, age range 17-75 years) who had undergone preoperative DTI-FT for FN identification. The mean tumor size among the studies ranged from 29 to 41.3 mm. Preoperative DTI-FT could not visualize the FN tract in 8 patients (3.4%) and its findings could not be verified in 3 patients (1.2%), were verified but discordant in 18 patients (7.6%), and were verified and concordant in 205 patients (87.1%). CONCLUSIONS Preoperative DTI-FT for FN identification is a useful adjunct in the surgical planning for large VSs (> 2.5 cm). A pooled analysis showed that DTI-FT successfully identifies the complete FN course in 96.6% of VSs (226 of 234 cases) and that FN identification by DTI-FT is accurate in 90.6% of cases (205 of 226 cases). Larger studies with DTI-FT-integrated neuronavigation are required to look at the direct benefit offered by this specific technique in preserving postoperative FN function.', 'publication': 'Neurosurg Focus'}, {'PMID': 29927823, 'Study Quality': '2', 'title': 'Value of Visualization of the Intraparotid Facial Nerve and Parotid Duct Using a Micro Surface Coil and Three-Dimensional Reversed Fast Imaging With Steady-State Precession and Diffusion-Weighted Imaging Sequence.', 'abstract': 'OBJECTIVE: To explore the value of micro surface coil combined with three-dimensional reversed fast imaging with steady-state precession and diffusion-weighted imaging (3D-PSIF-DWI) in displaying intraparotid facial nerves and parotid ducts.\nMETHODS: In total 24 healthy volunteers with no parotid disease underwent scanning of head and neck coil and 4-cm micro surface coil combined with 3D-PSIF-DWI prospectively. The obtained original images were processed through maximum intensity projection, multiplanar reconstruction, and curved planar reconstruction. The magnetic resonance imaging (MRI) signal characteristics of intraparotid structure, the subjective score of image quality, the signal intensity ratio (SIR) of facial nerve/parotid tissues (SIRN), and SIR of parotid duct/parotid tissues (SIRD) were calculated, and the displaying rates of the facial nerves and parotid ducts were observed. The Wilcoxon matched-sample signed rank sum test was used to compare the scores of head and neck coil and micro surface coil 3D-PSIF-DWI sequence images; paired-t test was used to compare SIRN and SIRD of the 2 groups; χ test was used to compare the displaying rate of the facial nerves and parotid ducts in the 2 groups.\nRESULTS: In total 24 volunteers successfully underwent MRI scan of parotid glands. On 3D-PSIF-DWI images, the parotid gland showed slightly low signal intensity, muscle tissues showed intermediate intensity, while the vessels showed slightly high or equal intensity; the parotid segment of facial nerves was displayed as a tortuous line-like high intensity, and the parotid duct showed curved high intensity, lymph nodes showed kidney-shaped, oval, or spindle-shaped high intensity. The subjective scores for head and neck coil and small coil images were (2.2\u200a±\u200a0.7) and (1.5\u200a±\u200a0.3) respectively, with significant difference (Z\u200a=\u200a-2.714, P\u200a=\u200a0.007), and image quality of micro surface coils was better than that of head and neck coil. The SIRNs of head and neck coil and micro surface coil images were 1.6\u200a±\u200a0.5 and 2.2\u200a±\u200a1.1 respectively; the SIRDs were 2.0\u200a±\u200a0.6 and 2.8\u200a±\u200a1.4 respectively, which showed significant differences (t\u200a=\u200a3.440, 3.639 respectively, P value was 0.001, 0.001 respectively). All facial nerve trunks could be displayed by head and neck coils and micro surface coils. On head and neck coil images, 46 sides of temporofacial division, 47 sides of cervicofacial division, 21 sides of temporal branches, 22 sides of zygomatic branches, 29 sides of buccal branches, 30 sides of marginal mandibular branches, 32 sides of cervical branches, and 28 sides of the parotid duct could be displayed. On micro coil images, 48 sides of temporofacial division, 48 sides of cervicofacial division, 37 sides of temporal branches, 39 sides of zygomatic branches, 42 sides of buccal branches, 35 sides of marginal mandibular branches, 46 sides of cervical branches, and 28 sides of the parotid duct could be displayed. The display number of first branches of the intraparotid facial nerve by these 2 methods had no significant difference, the number of the secondary branches and parotid duct had significant differences.\nCONCLUSION: Micro surface coil surpassed parotid MRI with 3D-PSIF-DWI sequence than neck coil, which can simultaneously clearly display the trunk and branches of the intraparotid facial nerves and parotid ducts.', 'publication': 'J Craniofac Surg'}, {'PMID': 29633003, 'Study Quality': '2', 'title': 'Facial nerve tractography: A new tool for the detection of perineural spread in parotid cancers.', 'abstract': 'OBJECTIVES: To determine whether facial nerve MR tractography is useful in detecting PeriNeural Spread in parotid cancers.\nMETHODS: Forty-five participants were enrolled. Thirty patients with surgically managed parotid tumors (15 malignant, 15 benign) were compared with 15 healthy volunteers. All of them had undergone 3T-MRI with diffusion acquisition and post-processing constrained spherical deconvolution-based tractography. Parameters of diffusion-weighted sequences were b-value 1,000 s/mm2, 32 directions. Two radiologists performed a blinded visual reading of tractographic maps and graded the facial nerve average pathlength and fractional anisotropy (FA). We also compared diagnostic accuracy of tractography with morphological MRI sequences to detect PeriNeural Spread. Non-parametric methods were used.\nRESULTS: Average pathlength was significantly higher in cases with PeriNeural Spread (39.86 mm [Quartile1: 36.27; Quartile3: 51.19]) versus cases without (16.23 mm [12.90; 24.90]), p<0.001. The threshold above which there was a significant association with PeriNeural Spread was set at 27.36 mm (Se: 100%; Sp: 84%; AUC: 0.96, 95% CI 0.904-1). There were no significant differences in FA between groups. Tractography map visual analyses directly displayed PeriNeural Spread in distal neural ramifications with sensitivity of 75%, versus 50% using morphological sequences.\nCONCLUSIONS: Tractography could be used to identify facial nerve PeriNeural Spread by parotid cancers.\nKEY POINTS: • Tractography could detect facial nerve PeriNeural Spread in parotid cancers. • The average pathlength parameter is increased in case of PeriNeural Spread. • Tractography could map PeriNeural Spread more precisely than conventional imaging.', 'publication': 'Eur Radiol'}, {'PMID': 29476993, 'Study Quality': '2', 'title': 'Multimodal Image-Based Virtual Reality Presurgical Simulation and Evaluation for Trigeminal Neuralgia and Hemifacial Spasm.', 'abstract': 'OBJECTIVE: To address the feasibility and predictive value of multimodal image-based virtual reality in detecting and assessing features of neurovascular confliction (NVC), particularly regarding the detection of offending vessels, degree of compression exerted on the nerve root, in patients who underwent microvascular decompression for nonlesional trigeminal neuralgia and hemifacial spasm (HFS).\nMETHODS: This prospective study includes 42 consecutive patients who underwent microvascular decompression for classic primary trigeminal neuralgia or HFS. All patients underwent preoperative 1.5-T magnetic resonance imaging (MRI) with T2-weighted three-dimensional (3D) sampling perfection with application-optimized contrasts by using different flip angle evolutions, 3D time-of-flight magnetic resonance angiography, and 3D T1-weighted gadolinium-enhanced sequences in combination, whereas 2 patients underwent extra experimental preoperative 7.0-T MRI scans with the same imaging protocol. Multimodal MRIs were then coregistered with open-source software 3D Slicer, followed by 3D image reconstruction to generate virtual reality (VR) images for detection of possible NVC in the cerebellopontine angle. Evaluations were performed by 2 reviewers and compared with the intraoperative findings.\nRESULTS: For detection of NVC, multimodal image-based VR sensitivity was 97.6% (40/41) and specificity was 100% (1/1). Compared with the intraoperative findings, the κ coefficients for predicting the offending vessel and the degree of compression were >0.75 (P < 0.001). The 7.0-T scans have a clearer view of vessels in the cerebellopontine angle, which may have significant impact on detection of small-caliber offending vessels with relatively slow flow speed in cases of HFS.\nCONCLUSIONS: Multimodal image-based VR using 3D sampling perfection with application-optimized contrasts by using different flip angle evolutions in combination with 3D time-of-flight magnetic resonance angiography sequences proved to be reliable in detecting NVC and in predicting the degree of root compression. The VR image-based simulation correlated well with the real surgical view.', 'publication': 'World Neurosurg'}, {'PMID': 29135869, 'Study Quality': '2', 'title': "Usefulness of High-Resolution 3D Multi-Sequences for Peripheral Facial Palsy: Differentiation Between Bell's Palsy and Ramsay Hunt Syndrome.", 'abstract': "OBJECTIVE: To investigate the usefulness of magnetic resonance imaging (MRI) including three-dimensional (3D) sequences in the differentiation between Bell's palsy (BP) and Ramsay Hunt syndrome (RHS).\nSTUDY DESIGN: A prospective study.\nSETTING: Tertiary care center.\nPATIENTS: Twenty patients: 15 patients with BP and five patients with RHS.\nINTERVENTION: Diagnostic.\nMAIN OUTCOME MEASURE: Clinical diagnosis (BP or RHS).\nRESULTS: The presence of hyperintensity on 3D-fluid-attenuated inversion recovery sequence (3D-FLAIR) and enhancement on gadolinium-enhanced (CE)-3D-FLAIR and CE-3D-T1-weighted image (3D-T1WI) along the internal auditory canal (IAC) wall were significantly associated with RHS (p\u200a<\u200a0.05). Hyperintensity in the inner ear was observed on pre- and postcontrast 3D-FLAIR, and enhancement of the cranial nerve (CN)-VIII was observed only on CE-3D-FLAIR. The presence of these findings also showed significant relationships with RHS (p\u200a<\u200a0.05). Moreover, thickening of the CN-VII in the fundus of the IAC in 3D-constructive interference on steady state sequence (3D-CISS) also showed a significant association with RHS (p\u200a<\u200a0.05). In contrast, the presence of hyperintensity of the CN-VII in the fundus of the IAC on 3D-FLAIR did not demonstrate a significant relationship (p\u200a=\u200a0.95), and enhancement in this region was observed in all cases on CE-3D-FLAIR and gadolinium-enhanced-three-dimensional-T1-weighted gradient echo sequence (CE-3D-T1WI).\nCONCLUSIONS: 3D MRI sequences are useful for differentiating RHS from BP. In particular, the enhancement in the CN-VIII and/or along the IAC wall are valuable findings, and CE-3D-FLAIR is the most useful sequence to evaluate these findings. Thickening of the CN-VII on 3D-CISS is also an important finding.", 'publication': 'Otol Neurotol'}, {'PMID': 28826862, 'Study Quality': '2', 'title': 'Identification of the Facial Nerve in Relation to Vestibular Schwannoma Using Preoperative Diffusion Tensor Tractography and Intraoperative Tractography-Integrated Neuronavigation System.', 'abstract': 'BACKGROUND: Preoperative visualization of the facial nerve could help neurosurgeons to prevent facial nerve injury during vestibular schwannoma surgery. Some studies have addressed diffusion tensor tractography (DTT) for preoperative identification of the facial nerve. However, few studies have focused on tractography-integrated neuronavigation for DTT verification. This study aimed to explore the appropriate DTT tracing parameters and evaluate the effect of intraoperative facial nerve tractography-integrated neuronavigation for verifying the DTT accuracy.\nMETHODS: Patients who underwent vestibular schwannoma surgery between September 2013 and August 2015 were included. Clinical features were recorded. All patients underwent preoperative DTT with 2 seed regions of interest and a variable fractional anisotropy threshold. Intraoperatively, the facial fiber tract guided by the neuronavigation was compared with the real location of facial nerve so that the accuracy of DTT was verified. Postoperative facial nerve function of each patients was followed up.\nRESULTS: Nineteen patients were enrolled in this study. Successful facial fiber tracts was obtained in 18 patients. In 17 of the 18 patients, intraoperative navigation confirmed DTT accuracy. The facial nerves were located on the anterior middle third of the tumor in 9 patients. Twelve months after surgery, facial nerve function was classified as grade I in 10 patients and grade II in 8 patients.\nCONCLUSIONS: We consider preoperative DTT with intraoperative tractography-integrated neuronavigation to be a useful method for identifying the location of the facial nerve. This method might improve facial nerve preservation.', 'publication': 'World Neurosurg'}, {'PMID': 28696161, 'Study Quality': '2', 'title': 'Comparison of normal facial nerve enhancement at 3T MRI using gadobutrol and gadopentetate dimeglumine.', 'abstract': 'Background and purpose The facial nerve is unique among cranial nerves in demonstrating normal enhancement of particular segments. The effect of varying T1 relaxivities of gadolinium-based contrast agents on facial nerve enhancement is unclear. In this study, we assess differences in normal facial nerve enhancement with two different gadolinium-based contrast agents, gadobutrol and gadopentetate dimeglumine. In addition, we evaluate differences in facial nerve enhancement with spin-echo (SE) T1 versus 3D inversion recovery prepared fast spoiled gradient-echo (FSPGR) post-contrast sequences. Methods A total of 140 facial nerves in 70 individuals were evaluated (70 with gadobutrol and 70 with gadopentetate dimeglumine) by two blinded reviewers. Differences in enhancement of facial nerve segments between the two agents were analyzed. Differences in enhancement between SE T1 and FSPGR imaging were also evaluated. Results There was no significant difference in facial nerve enhancement between gadobutrol and gadopentetate dimeglumine. Enhancement was commonly observed in the geniculate, tympanic and mastoid segments (98%-100%) with either contrast agent; enhancement was less common in the labyrinthine segments (9%-14%) and lateral canalicular segment (2%-5%). There was a smaller enhancing proportion of labyrinthine and tympanic segments with FSPGR as compared to SE T1 images with gadobutrol. Conclusion There is no significant difference in overall enhancement of the facial nerve between gadobutrol and gadopentetate dimeglumine. Mild enhancement of the lateral canalicular portion of the facial nerve may be a normal finding. With FSPGR sequence, there is lesser perceived enhancement of the labyrinthine and tympanic segments of the facial nerve with gadobutrol.', 'publication': 'Neuroradiol J'}, {'PMID': 27625239, 'Study Quality': '2', 'title': 'Prediction of facial nerve position in large vestibular schwannomas using diffusion tensor imaging tractography and its intraoperative correlation.', 'abstract': 'OBJECTIVE: Resection of large Vestibular Schwannomas (VSs) can be associated with postoperative facial nerve injury. Diffusion-based tractography has emerged as a powerful tool for three-dimensional imaging and reconstruction of white matter fibers; however, tractography of the cranial nerves has not been well studied. In this prospective study, we aim to predict the position of facial nerve in large VSs (>3 cm) using Diffusion Tensor Imaging (DTI) tractography and correlate it with the intraoperative finding of the position of facial nerve.\nMATERIALS AND METHODS: Twenty patients with a large VS (>3 cm) undergoing surgery were subjected to preoperative DTI to predict the position of the facial nerve in relation to the tumor. The surgeon was blinded to the results of the preoperative DTI tractography. A comparative analysis was then made during operation. The location of the facial nerve in relation to the tumor was recorded during surgery using facial nerve stimulator.\nRESULTS: Of the 20 patients who underwent DTI tractography, it was not possible to preoperatively identify facial nerve in one patient. In another patient, although DTI tractography predicted the position of facial nerve, it was not identified intraoperatively. In the remaining 18 patients, DTI tractography accurately predicted the facial nerve position. The predicted position was in synchronization with the intraoperative facial nerve position in 16 patients (89% concordance). It was discordant in two patients (11%), but this was not found to be statistically significant (P = -0.3679).\nCONCLUSION: This study validates the reliability of facial nerve DTI-based fiber tracking for prediction of the facial nerve position in patients with large VSs. The reliable preoperative visualization of facial nerve location in relation to the VS will allow surgeons to plan tumor removal accordingly and may increase the safety of surgery.', 'publication': 'Neurol India'}, {'PMID': 26905823, 'Study Quality': '2', 'title': 'Diffusion Tensor Imaging Tractography of the Facial Nerve in Patients With Cerebellopontine Angle Tumors.', 'abstract': 'OBJECTIVE: To demonstrate the utility of diffusion tensor imaging (DTI) fiber tractography of the facial nerve in patients with cerebellopontine angle (CPA) tumors.\nSTUDY DESIGN: Prospective.\nSETTING: Tertiary referral center.\nPATIENTS: DTI technique was established in 113 patients without tumors and in 28 patients with CPA tumors. Subsequently, DTI results were compared with intraoperative findings in 21 patients with medium and large-sized tumors, treated surgically via a translabyrinthine approach.\nINTERVENTION: Three Tesla magnetic resonance (MR) was used for DTI tractography. For patients without CPA tumors, the scanning protocol was 32 directions with a 3 × 3 × 3\u200amm voxel size. For CPA tumor patients, scanning protocol was 32 directions with a 2 × 2 × 2\u200amm voxel size. DTI data were used to track the facial nerve.\nMAIN OUTCOME MEASURES: Facial nerve identification rate.\nRESULTS: Facial nerve identification rate in MR-DTI was 97% and 100% in patients without tumors and in patients with tumors of the CPA of the internal auditory canal that were not treated surgically, respectively. MR-DTI identification of the facial nerve was successful in 20 patients who were treated surgically (95%). Good agreement between surgical findings and MR-DTI results was found in 19 patients (90%).\nCONCLUSION: MR DTI tractography is an effective technique in positively identifying the position of the facial nerve in patients with CPA tumors.', 'publication': 'Otol Neurotol'}, {'PMID': 26449562, 'Study Quality': '2', 'title': 'Parotid gland tumours: MR tractography to assess contact with the facial nerve.', 'abstract': "OBJECTIVES: To assess the feasibility of intraparotid facial nerve (VIIn) tractographic reconstructions in estimating the presence of a contact between the VIIn and the tumour, in patients requiring surgical resection of parotid tumours.\nMETHODS: Patients underwent MR scans with VIIn tractography calculated with the constrained spherical deconvolution model. The parameters of the diffusion sequence were: b-value of 1000\xa0s/mm(2); 32 directions; voxel size: 2\xa0mm isotropic; scan time: 9'31'. The potential contacts between VIIn branches and tumours were estimated with different initial fractional anisotropy (iFA) cut-offs compared to surgical data. Surgeons were blinded to the tractography reconstructions and identified both nerves and contact with tumours using nerve stimulation and reference photographs.\nRESULTS: Twenty-six patients were included in this study and the mean patient age was 55.2\xa0years. Surgical direct assessment of VIIn allowed identifying 0.1 as the iFA threshold with the best sensitivity to detect tumour contact. In all patients with successful VIIn identification by tractography, surgeons confirmed nerve courses as well as lesion location in parotid glands. Mean VIIn branch FA values were significantly lower in cases with tumour contact (t-test; p\u2009≤\u20090.01).\nCONCLUSIONS: This study showed the feasibility of intraparotid VIIn tractography to identify nerve contact with parotid tumours.\nKEY POINTS: • Diffusion imaging is an efficient method for highlighting the intraparotid VIIn. • Visualization of the VIIn may help to better manage patients before surgery. • We bring new insights to future trials for patients with VIIn dysfunction. • We aimed to provide radio-anatomical references for further studies.", 'publication': 'Eur Radiol'}, {'PMID': 26519891, 'Study Quality': '2', 'title': 'Microvascular decompression and MRI findings in trigeminal neuralgia and hemifacial spasm. A single center experience.', 'abstract': 'OBJECTIVE: For patients with medically unresponsive trigeminal neuralgia (TIC) and hemifacial spasm (HS), surgical microvascular decompression (MVD) is the procedure of choice. The authors of this report sought to review their outcomes with MVD in patients with TIC and HS, and the success of preoperative magnetic resonance imaging (MRI) in identifying the offending vascular compression.\nMETHODS: Since 2004, there were a total of 51 patients with TIC and 12 with HS with available MRI scans. All patients underwent preoperative MRI to rule out non-surgical etiologies for facial pain and facial spasm, and confirm vascular compression. Follow-up after surgery was 13 ± 22 months for the patients with TIC and 33 ± 27 months for the patients with HS.\nRESULTS: There were 45 responders to MVD in the TIC cohort (88%), with a Visual Analog Score (VAS) of 1 ± 3. All patients with HS responded to MVD between 25 and 100%, with a mean of 75 ± 22%. Wound complications occurred in 10% of patients with MVD for TIC, and 1 patient reported hearing loss after MVD for HS, documented by audiogram. The congruence rate between the preoperative MRI and operative findings of vascular compression was 84% in TIC and 75% in HS.\nCONCLUSION: MVD is an effective and safe modality of treatment for TIC and HS. In addition to ruling out structural lesions, MRI can offer additional information by highlighting vascular loops associated with compressions. On conventional scans as obtained here, the resolution of MRI was congruent with operative findings in 84% in TIC and 75% in HS. This review emphasizes that the decision to undertake MVD in TIC or HS should be based on clinical diagnosis and not visualization of a compressing vessel by MRI. Conversely, the presence of a compressing vessel by MRI demands perseverance by the surgeon until the nerve is decompressed.', 'publication': 'Clin Neurol Neurosurg'}, {'PMID': 25430858, 'Study Quality': '2', 'title': 'MRI findings in patients with a history of failed prior microvascular decompression for hemifacial spasm: how to image and where to look.', 'abstract': 'BACKGROUND AND PURPOSE: A minority of patients who undergo microvascular decompression for hemifacial spasm do not improve after the first operation. We sought to determine the most common locations of unaddressed neurovascular contact in patients with persistent or recurrent hemifacial spasm despite prior microvascular decompression.\nMATERIALS AND METHODS: Eighteen patients with a history of a microvascular decompression presented with persistent hemifacial spasm. All patients underwent thin-section steady-state free precession MR imaging. Fourteen patients underwent repeat microvascular decompression at our institution. Images were evaluated for the following: the presence of persistent vascular compression of the facial nerve, type of culprit vessel (artery or vein), name of the culprit artery, segment of the nerve in contact with the vessel, and location of the point of contact relative to the existing surgical pledget. The imaging findings were compared with the operative findings.\nRESULTS: In 12 of the 18 patients (67%), persistent vascular compression was identified by imaging. In 11 of these 12 patients, the culprit vessel was an artery. Compression of the attached segment (along the ventral surface of the pons) was identified in most patients (58%, 7/12). The point of contact was proximal to the surgical pledget in most patients (83%, 10/12). The imaging interpretation was concordant with the surgical results regarding artery versus vein in 86% of cases and regarding the segment of the nerve contacted in 92%.\nCONCLUSIONS: In patients with persistent hemifacial spasm despite microvascular decompression, the unaddressed vascular compression is typically proximal to the previously placed pledget, usually along the attached segment of the nerve. Re-imaging with high-resolution T2-weighted MR imaging will usually identify the culprit vessel.', 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 25044001, 'Study Quality': '2', 'title': 'Thin-slice T2 MRI imaging predicts vascular pathology in hemifacial spasm: a case-control study.', 'abstract': "Hemifacial spasm (HFS) is a condition that may severely reduce patients' quality of life. We sought to determine the sensitivity and specificity of thin-slice T2 magnetic resonance imaging (MRI) for detecting vascular compression in HFS patients. Prospective information was collected on 28 patients with HFS who presented to our center between March 2011 and March 2012 with thin-slice T2 MR imaging. The sensitivity and specificity for differentiating patients from controls were calculated. Sensitivities were 78.6% and 92.9% for the blinded radiologists and 75% for the partially blinded neurosurgeon. Specificities were 42.9% and 28.6% for the blinded radiologists and 75% for the partially blinded neurosurgeon. Magnetic resonance imaging of the facial nerve can guide clinicians in selecting patients who are good surgical candidates. Thin-slice T2 MRI should be viewed as supportive rather than diagnostic.", 'publication': 'Mov Disord'}, {'PMID': 24758667, 'Study Quality': '2', 'title': 'Redefining normal facial nerve enhancement: healthy subject comparison of typical enhancement patterns--unenhanced and contrast-enhanced spin-echo versus 3D inversion recovery-prepared fast spoiled gradient-echo imaging.', 'abstract': 'OBJECTIVE: Normal facial nerve enhancement patterns derived from spin-echo (SE) sequences have not been systematically compared on contrast-enhanced 3D inversion recovery-prepared fast spoiled gradient-echo (IR-FSPGR) sequences, now in widespread use. We hypothesize that features unique to IR-FSPGR may engender differences in the appearance of the normal facial nerve, which may confound analysis of pathologic enhancement. We compared unenhanced and contrast-enhanced SE and IR-FSPGR sequences in a cohort of patients without facial nerve pathology.\nMATERIALS AND METHODS: Twenty-three patients without facial nerve pathology were examined. Unenhanced and contrast-enhanced signal intensity (SI) of seven facial nerve segments was assessed on SE and IR-FSPGR by two neuroradiologists. SI was assigned a value of 0-3 (0, absent; 1, faint; 2, equivalent to brain; 3, equivalent to enhancing dural sinus). Statistically significant differences were assessed for each segment.\nRESULTS: Significantly higher unenhanced and contrast-enhanced SI was present in most facial nerve segments on IR-FSPGR compared with SE, including cisternal, canalicular, labyrinthine, and geniculate segments (p ≤ 0.01). Enhancement patterns were generally similar; however, significant enhancement of the labyrinthine segment was detected only on SE (p = 0.011). For unenhanced images, mean kappa statistic was 0.32, and for the contrast-enhanced images, mean kappa statistic was 0.04, implying fair and slight agreement between readers, respectively.\nCONCLUSION: Significantly greater SI is observed in most facial nerve segments on both unenhanced and contrast-enhanced IR-FSPGR among healthy subjects and may be misinterpreted as pathologic when evaluated in the context of existing enhancement paradigms. Examiners should remain cognizant of normal deviations from expected enhancement patterns in IR-FSPGR imaging to avoid misdiagnosis and other interpretive pitfalls.', 'publication': 'AJR Am J Roentgenol'}, {'PMID': 20645285, 'Study Quality': '2', 'title': 'Detecting and defining the anatomic extent of large nerve perineural spread of malignancy: comparing "targeted" MRI with the histologic findings following surgery.', 'abstract': 'BACKGROUND: The accurate preoperative identification of the extent of perineural spread (PNS) of malignancy along a cranial nerve is vital to the design of an appropriate surgical resection. Our purpose was to determine the sensitivity of targeted MRI in predicting the presence of disease and the anatomic extent of spread when compared with histologic findings.\nMETHODS: A retrospective review was performed of 25 patients with PNS who had targeted MRI and surgery to excise perineural tumor (2002-2008).\nRESULTS: MRI detected PNS in 30 of 30 nerves (100%) with 1 false positive. MRI correctly identified the extent of spread based on histology in 25 of 30 nerves (83.3%). In 4 of 30 cases (13.3%) MRI underestimated the extent of spread proximal to the Gasserian ganglion that, if diagnosed preoperatively, may have deemed the patient inoperable.\nCONCLUSIONS: MRI demonstrated the presence and anatomic extent of PNS in the majority of cases. MRI may underestimate microscopic spread proximal to the Gasserian ganglion.', 'publication': 'Head Neck'}, {'PMID': 23578676, 'Study Quality': '2', 'title': 'High-resolution MRI of the intraparotid facial nerve based on a microsurface coil and a 3D reversed fast imaging with steady-state precession DWI sequence at 3T.', 'abstract': 'BACKGROUND AND PURPOSE: 3D high-resolution MR imaging can provide reliable information for defining the exact relationships between the intraparotid facial nerve and adjacent structures. The purpose of this study was to explore the clinical value of using a surface coil combined with a 3D-PSIF-DWI sequence in intraparotid facial nerve imaging.\nMATERIALS AND METHODS: Twenty-one healthy volunteers underwent intraparotid facial nerve scanning at 3T by using the 3D-PSIF-DWI sequence with both the surface coil and the head coil. Source images were processed with MIP and MPR to better delineate the intraparotid facial nerve and its branches. In addition, the SIR of the facial nerve and parotid gland was calculated. The number of facial nerve branches displayed by these 2 methods was calculated and compared.\nRESULTS: The display rates of the main trunk, divisions (cervicofacial, temporofacial), and secondary branches of the intraparotid facial nerve were 100%, 97.6%, and 51.4% by head coil and 100%, 100%, and 83.8% by surface coil, respectively. The display rate of secondary branches of the intraparotid facial nerve by these 2 methods was significantly different (P < .05). The SIRs of the intraparotid facial nerve/parotid gland in these 2 methods were significantly different (P < .05) at 1.37 ± 1.06 and 1.89 ± 0.87, respectively.\nCONCLUSIONS: The 3D-PSIF-DWI sequence combined with a surface coil can better delineate the intraparotid facial nerve and its divisions than when it is combined with a head coil, providing better image contrast and resolution. The proposed protocol offers a potentially useful noninvasive imaging sequence for intraparotid facial nerve imaging at 3T.', 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 22207300, 'Study Quality': '2', 'title': 'MR diagnosis of facial neuritis: diagnostic performance of contrast-enhanced 3D-FLAIR technique compared with contrast-enhanced 3D-T1-fast-field echo with fat suppression.', 'abstract': 'BACKGROUND AND PURPOSE: Current MRI with the CE T1-weighted sequence plays a limited role in the evaluation of facial neuritis due to prominent normal facial nerve enhancement. Our purpose was to retrospectively investigate the usefulness of the CE 3D-FLAIR sequence compared with the CE 3D-T1-FFE sequence in facial neuritis patients.\nMATERIALS AND METHODS: We assessed 36 consecutive patients who underwent temporal bone MR imaging at 3T for idiopathic facial palsy. Two readers independently reviewed CE 3D-T1-FFE and CE 3D-FLAIR images to determine the degree of enhancement in each of 5 segments of the facial nerve. We compared AUCs using the Z-test, compared diagnostic performance of 2 MR techniques with the McNemar test, and evaluated interobserver agreement. The Pearson χ(2) test was used for each segment of the facial nerve.\nRESULTS: The AUC of CE 3D-FLAIR (reader 1, 0.754; reader 2, 0.746) was greater than that of CE 3D-T1-FFE (reader 1, 0.624; reader 2, 0.640; P < .001). The diagnostic sensitivities, specificities, and accuracies were 97.2%, 86.1%, and 91.7%, respectively, for CE 3D-FLAIR, and 100%, 56.9%, and 78.5%, respectively, for CE 3D-T1-FFE. The specificity and accuracy of CE 3D-FLAIR were greater than those of CE 3D-T1-FFE (specificity, P = .029; accuracy, P = .008). The interobserver agreements for CE 3D-FLAIR (κ-value, 0.831) and CE 3D-T1-FFE (κ-value, 0.694) were excellent. Enhancement of the canalicular and anterior genu segments on CE 3D-FLAIR were significantly correlated with the occurrence of facial neuritis (P < .001 for canalicular; P = .032 and 0.020 for anterior genu by reader 1 and reader 2, respectively).\nCONCLUSIONS: CE 3D-FLAIR can improve the specificity and overall accuracy of MR imaging in patients with idiopathic facial palsy.', 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 18596507, 'Study Quality': '4', 'title': 'Blood supply of the facial nerve in the middle fossa: the petrosal artery.', 'abstract': 'OBJECTIVE: To define the arterial supply to the facial nerve that crosses the floor of the middle cranial fossa.\nMETHODS: Twenty-five middle fossae from adult cadaveric-injected specimens were examined under 3 to 40x magnification.\nRESULTS: The petrosal branch of the middle meningeal artery is the sole source of supply that crossed the floor of the middle fossa to irrigate the facial nerve. The petrosal artery usually arises from the first 10-mm segment of the middle meningeal artery after it passes through the foramen spinosum, but it can arise within or just below the foramen spinosum. The petrosal artery is commonly partially or completely hidden in the bone below the middle fossa floor. It most commonly reaches the facial nerve by passing through the bone enclosing the geniculate ganglion and tympanic segment of the nerve and less commonly by passing through the hiatus of the greater petrosal nerve. The petrosal artery frequently gives rise to a branch to the trigeminal nerve. The middle meningeal artery was absent in one of the 25 middle fossae, and a petrosal artery could not be identified in four middle fossae. The petrosal arteries were divided into three types based on their pattern of supply to the facial nerve.\nCONCLUSION: The petrosal artery is at risk of being damaged during procedures in which the dura is elevated from the floor of the middle fossa, the middle fossa floor is drilled, or the middle meningeal artery is embolized or sacrificed. Several recommendations are offered to avoid damaging the facial nerve supply while performing such interventions.', 'publication': 'Neurosurgery'}, {'PMID': 26178307, 'Study Quality': '2', 'title': '3T MRI evaluation of large nerve perineural spread of head and neck cancers.', 'abstract': "INTRODUCTION: Accurate definition of the presence and extent of large nerve perineural spread (PNS) is a vital component in planning appropriate surgery and radiotherapy for head and neck cancers. Our research aimed to define the sensitivity and specificity of 3T MRI in detecting the presence and extent of large nerve PNS, compared with histologic evaluation.\nMETHODS: Retrospective review of surgically proven cases of large nerve PNS in patients with preoperative 3T MRI performed as high resolution neurogram.\nRESULTS: 3T MRI had a sensitivity of 95% and a specificity of 84%, detecting PNS in 36 of 38 nerves and correctly identifying uninvolved nerves in 16 of 19 cases. It correctly identified the zonal extent of spread in 32 of 36 cases (89%), underestimating the extent in three cases and overestimating the extent in one case.\nCONCLUSION: Targeted 3T MRI is highly accurate in defining the presence and extent of large nerve PNS in head and neck cancers. However, there is still a tendency to undercall the zonal extent due to microscopic, radiologically occult involvement. Superficial large nerve involvement also remains a difficult area of detection for radiologists and should be included as a 'check area' for review. Further research is required to define the role radiation-induced neuritis plays in the presence of false-positive PNS on MRI.", 'publication': 'J Med Imaging Radiat Oncol'}, {'PMID': 17576903, 'Study Quality': '2', 'title': 'The sensitivity and specificity of high-resolution imaging in evaluating perineural spread of adenoid cystic carcinoma to the skull base.', 'abstract': 'OBJECTIVE: To evaluate the sensitivity and specificity of computed tomography (CT) and magnetic resonance imaging (MRI) in detecting perineural spread (PNS) of adenoid cystic carcinoma of the head and neck to the skull base.\nDESIGN: Adenoid cystic carcinoma of the head and neck frequently exhibits PNS across the skull base. Failure to detect PNS before treatment can have significant negative consequences on the planning and outcome of therapy. High-resolution CT, MRI, or both are used to evaluate the presence of PNS; however, their accuracy in detecting perineural involvement has not yet been determined.\nPATIENTS: Twenty-six consecutive patients with adenoid cystic carcinoma, who were treated with cranial base resection, were included in this study. The surgical resection specimens of all patients were thoroughly examined by 1 pathologist for the presence of PNS along cranial nerves or their named branches. A total of 38 nerves were examined, and PNS was defined as the presence of tumor in the perineural or endoneural space. The results of the preoperative imaging studies (CT and/or MRI) were then reviewed retrospectively by 1 head and neck radiologist, who was unaware of the pathology report. Radiological evidence of PNS was considered to be present on CT, MRI, or both if nerves showed evidence of thickening (regardless of enhancement), contrast enhancement (regardless of size), or widening of their bony foramina or canals.\nRESULTS: Histopathologic evidence of PNS was present in 25 (66%) of 38 named nerves. The sensitivity and specificity of CT in detecting PNS were 88% and 89%, respectively. Magnetic resonance imaging had a higher sensitivity (100%) and specificity (85%).\nCONCLUSIONS: Perineural spread across the skull base is a frequent occurrence in patients with adenoid cystic carcinoma of the head and neck. Magnetic resonance imaging has a higher sensitivity and specificity than CT in detecting PNS along the base of the skull.', 'publication': 'Arch Otolaryngol Head Neck Surg'}, {'PMID': 24431233, 'Study Quality': '4', 'title': 'Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center.', 'abstract': "OBJECTIVES/HYPOTHESIS: To evaluate the range and incidence of facial palsy etiologies in cases presenting to a tertiary facial nerve center, and to review the broad and evolving spectrum of diagnostic and management approaches to the condition.\nSTUDY DESIGN: Retrospective chart review.\nMETHODS: Records of patients referred for facial weakness between 2003 and 2013 were reviewed for cases of facial palsy. Cases of muscle dysfunction and primary hemifacial spasm were excluded. The remainder were analyzed by age, sex, and diagnosis. Diagnostic and treatment strategies were reviewed.\nRESULTS: There were 1,989 records that met inclusion criteria. Bell's palsy accounted for 38% of cases, acoustic neuroma resections 10%, cancer 7%, iatrogenic injuries 7%, varicella zoster 7%, benign lesions 5%, congenital palsy 5%, Lyme disease 4%, and other causes 17%. Sixty-one percent of patients were female. Mean age at presentation was 44.5 years (±18.6 years). Diagnoses were revealed primarily by history, though serial physical examinations, radiography, and hematologic testing also contributed. Management strategies included observation, physical therapy, pharmacological therapy, chemodenervation, facial nerve exploration, decompression, repair, and the full array of static and dynamic surgical interventions.\nCONCLUSIONS: Bell's palsy remains the most common facial palsy; females present more often for evaluation. Comprehensive diagnostic investigation is mandatory in atypical cases, and thorough management must be multidisciplinary. The algorithms presented herein outline a single center's approach to the facial palsy patient, providing a framework that clinicians caring for these patients may adapt to their specific settings.\nLEVEL OF EVIDENCE: 2b.", 'publication': 'Laryngoscope'}, {'PMID': 31624121, 'Study Quality': '4', 'title': 'MR Imaging of the Extracranial Facial Nerve with the CISS Sequence.', 'abstract': 'BACKGROUND AND PURPOSE: MR imaging is not routinely used to image the extracranial facial nerve. The purpose of this study was to determine the extent to which this nerve can be visualized with a CISS sequence and to determine the feasibility of using that sequence for locating the nerve relative to tumor.\nMATERIALS AND METHODS: Thirty-two facial nerves in 16 healthy subjects and 4 facial nerves in 4 subjects with parotid gland tumors were imaged with an axial CISS sequence protocol that included 0.8-mm isotropic voxels on a 3T MR imaging system with a 64-channel head/neck coil. Four observers independently segmented the 32 healthy subject nerves. Segmentations were compared by calculating average Hausdorff distance values and Dice similarity coefficients.\nRESULTS: The primary bifurcation of the extracranial facial nerve into the superior temporofacial and inferior cervicofacial trunks was visible on all 128 segmentations. The mean of the average Hausdorff distances was 1.2 mm (range, 0.3-4.6 mm). Dice coefficients ranged from 0.40 to 0.82. The relative position of the facial nerve to the tumor could be inferred in all 4 tumor cases.\nCONCLUSIONS: The facial nerve can be seen on CISS images from the stylomastoid foramen to the temporofacial and cervicofacial trunks, proximal to the parotid plexus. Use of a CISS protocol is feasible in the clinical setting to determine the location of the facial nerve relative to tumor.', 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 2114760, 'Study Quality': '4', 'title': "Contrast-enhanced MR imaging of the facial nerve in 11 patients with Bell's palsy.", 'abstract': "Contrast-enhanced MR images (at 1.5 T) were obtained in 11 patients with facial palsy. The group included five people with acute idiopathic facial (Bell's) palsy, three with chronic idiopathic facial palsy, and one each with acute facial palsy after local radiation therapy, acute facial palsy resulting from herpes zoster virus infection, and facial palsy caused by facial neuroma. Eight of the 11 patients demonstrated marked enhancement of the affected facial nerve from the labyrinthine portion through the descending canal. Three patients also demonstrated mild enhancement of the distal canalicular portion of the facial nerve, simulating small distal acoustic neuromas. No difference in the pattern of enhancement between the acute or chronic Bell's palsy patients was seen. Radiographic resolution appeared to lag behind clinical resolution. The facial neuroma appeared distinct from the other lesions as a focally enhancing mass. The enhancement pattern in the Bell's group correlated with the histopathologic features of Bell's palsy and is consistent with the viral hypothesis of the syndrome. Thin-section contrast-enhanced MR scans are recommended for individuals with atypical presentation of facial paralysis. In the proper clinical setting, contrast-enhanced MR imaging may permit a positive radiographic diagnosis of Bell's palsy, which has previously been a diagnosis of exclusion.", 'publication': 'AJNR Am J Neuroradiol'}, {'PMID': 18618345, 'Study Quality': '2', 'title': "Clinical significance of quantitative analysis of facial nerve enhancement on MRI in Bell's palsy.", 'abstract': "CONCLUSIONS: Quantitative analysis of the facial nerve on the lesion side as well as the normal side, which allowed for more accurate measurement of facial nerve enhancement in patients with facial palsy, showed statistically significant correlation with the initial severity of facial nerve inflammation, although little prognostic significance was shown.\nOBJECTIVES: This study investigated the clinical significance of quantitative measurement of facial nerve enhancement in patients with Bell's palsy by analyzing the enhancement pattern and correlating MRI findings with initial severity of facial palsy and clinical outcome.\nSUBJECTS AND METHODS: Facial nerve enhancement was measured quantitatively by using the region of interest on pre- and postcontrast T1-weighted images in 44 patients diagnosed with Bell's palsy. The signal intensity increase on the lesion side was first compared with that of the contralateral side and then correlated with the initial degree of facial palsy and prognosis.\nRESULTS: The lesion side showed significantly higher signal intensity increase compared with the normal side in all of the segments except for the mastoid segment. Signal intensity increase at the internal auditory canal and labyrinthine segments showed correlation with the initial degree of facial palsy but no significant difference was found between different prognostic groups.", 'publication': 'Acta Otolaryngol'}]
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strong
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usually appropriate
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may be appropriate
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usually not appropriate
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may be appropriate (disagreement)
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A
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Measure the appropriateness of undertaking a Magnetic Resonance Imaging head without Intravenous contrast on a patient with the following characteristics: follow-up for clinically localized renal cell carcinoma; post radical or partial nephrectomy.
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usually not appropriate
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[{'PMID': 23665399, 'Study Quality': '4', 'title': 'Follow-up for Clinically Localized Renal Neoplasms: AUA Guideline.', 'abstract': 'PURPOSE: The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy.\nMATERIALS AND METHODS: A systematic literature review identified published articles in the English literature between January 1999 and 2011 relevant to key questions specified by the Panel related to kidney neoplasms and their follow-up (imaging, renal function, markers, biopsy, prognosis). Study designs consisting of clinical trials (randomized or not), observational studies (cohort, case-control, case series) and systematic reviews were included.\nRESULTS: Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of postoperative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathological tumor stage.\nCONCLUSIONS: Evaluation for patients on active surveillance and following definitive therapy for renal neoplasms should include physical examination, renal function, serum studies and imaging and should be tailored according to recurrence risk, comorbidities and monitoring for treatment sequelae. Expert opinion determined a judicious course of monitoring/surveillance that may change in intensity as surgical/ablative therapies evolve, renal biopsy accuracy improves and more long-term follow-up data are collected. The beneficial impact of careful follow-up will also need critical evaluation as further study is completed.', 'publication': 'J Urol'}, {'PMID': 28596261, 'Study Quality': '4', 'title': 'Kidney Cancer, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology.', 'abstract': 'The NCCN Guidelines for Kidney Cancer provide multidisciplinary recommendations for the clinical management of patients with clear cell and non-clear cell renal carcinoma. These guidelines are developed by a multidisciplinary panel of leading experts from NCCN Member Institutions consisting of medical oncologists, hematologists and hematologic oncologists, radiation oncologists, urologists, and pathologists. The NCCN Guidelines are in continuous evolution and are updated annually or sometimes more often, if new high-quality clinical data become available in the interim.', 'publication': 'J Natl Compr Canc Netw'}, {'PMID': 30803729, 'Study Quality': '4', 'title': 'European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update.', 'abstract': 'CONTEXT: The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.\nOBJECTIVE: To provide an updated RCC guideline based on standardised methodology including systematic reviews, which is robust, transparent, reproducible, and reliable.\nEVIDENCE ACQUISITION: For the 2019 update, evidence synthesis was undertaken based on a comprehensive and structured literature assessment for new and relevant data. Where necessary, formal systematic reviews adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were undertaken. Relevant databases (Medline, Cochrane Libraries, trial registries, conference proceedings) were searched until June 2018, including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm, systematic reviews, and meta-analyses. Where relevant, risk of bias (RoB) assessment, and qualitative and quantitative syntheses of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Clinical practice recommendations were developed and issued based on the modified GRADE framework.\nEVIDENCE SYNTHESIS: All chapters of the RCC guidelines were updated based on a structured literature assessment, for prioritised topics based on the availability of robust data. For RCTs, RoB was low across studies. For most non-RCTs, clinical and methodological heterogeneity prevented pooling of data. The majority of included studies were retrospective with matched or unmatched cohorts, based on single- or multi-institutional data or national registries. The exception was for the treatment of metastatic RCC, for which there were several large RCTs, resulting in recommendations based on higher levels of evidence.\nCONCLUSIONS: The 2019 RCC guidelines have been updated by the multidisciplinary panel using the highest methodological standards. These guidelines provide the most reliable contemporary evidence base for the management of RCC in 2019.\nPATIENT SUMMARY: The European Association of Urology Renal Cell Carcinoma Guideline Panel has thoroughly evaluated the available research data on kidney cancer to establish international standards for the care of kidney cancer patients.', 'publication': 'Eur Urol'}]
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limited
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usually not appropriate
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may be appropriate
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usually appropriate
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may be appropriate (disagreement)
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A
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Weigh the appropriateness of administering a Computed Tomography head without and with Intravenous contrast on a patient with the following characteristics: child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast Computed Tomography Next imaging study.
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usually not appropriate
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[{'PMID': 24156863, 'Study Quality': '4'}]
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limited
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may be appropriate
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may be appropriate (disagreement)
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usually appropriate
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usually not appropriate
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D
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Measure the appropriateness of undertaking a Ultrasound chest on a patient with the following characteristics: recent pneumonia with suspected parapneumonic effusion or empyema. Initial imaging.
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may be appropriate (disagreement)
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[{'PMID': 19933660, 'Study Quality': '3'}, {'PMID': 11762545, 'Study Quality': '2'}, {'PMID': 30675767, 'Study Quality': '2'}, {'PMID': 27709281, 'Study Quality': '3'}, {'PMID': 19616366, 'Study Quality': '2'}, {'PMID': 11127008, 'Study Quality': '2'}, {'PMID': 33033148, 'Study Quality': '4'}, {'PMID': 27613540, 'Study Quality': '3', 'title': 'The accuracy of pleural ultrasonography in diagnosing complicated parapneumonic pleural effusions.', 'abstract': 'We compared the accuracy of pleural ultrasound versus chest CT versus chest radiograph (CXR) to determine radiographic complexity in predicting a complicated parapneumonic effusion (CPPE) defined by pleural fluid analysis. 66 patients with parapneumonic effusions were identified with complete data. Pleural ultrasound had a sensitivity of 69.2% (95% CI 48.2% to 85.7%) and specificity of 90.0% (95% CI 76.3% to 97.2%). Chest CT had a sensitivity of 76.9% (95% CI 56.3% to 91.0%) and specificity of 65.0% (95% CI 48.3% to 79.4%). CXR had a sensitivity of 61.5% (95% CI 40.6% to 79.8%) and specificity of 60.0% (95% CI 43.3% to 75.1%). Pleural ultrasound appears to be a superior modality to rule in a CPPE when compared with chest CT and CXR.', 'publication': 'Thorax'}, {'PMID': 28274565, 'Study Quality': '4', 'title': 'The American Association for Thoracic Surgery consensus guidelines for the management of empyema.', 'abstract': None, 'publication': 'J Thorac Cardiovasc Surg'}]
|
expert opinion
|
usually appropriate
|
usually not appropriate
|
may be appropriate
|
may be appropriate (disagreement)
|
D
|
Investigate the appropriateness of performing a Ultrasound duplex Doppler abdomen on a patient with the following characteristics: known multiorgan system arterial occlusions. Suspected embolic etiology. Next imaging study to determine source.
|
may be appropriate
|
[{'PMID': 21482138, 'Study Quality': '4'}]
|
limited
|
usually appropriate
|
may be appropriate
|
usually not appropriate
|
may be appropriate (disagreement)
|
B
|
Survey the appropriateness of delivering a Magnetic Resonance Angiography chest without and with Intravenous contrast on a patient with the following characteristics: acute nonspecific chest pain; low probability of coronary artery disease. Initial imaging.
|
usually not appropriate
|
[{'PMID': 27533160, 'Study Quality': '4', 'title': 'Acute Aortic Dissection and Intramural Hematoma: A Systematic Review.', 'abstract': 'IMPORTANCE: Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary.\nOBJECTIVE: To systematically review the current evidence on diagnosis and treatment of AAS.\nEVIDENCE REVIEW: Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed.\nFINDINGS: Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n\u2009=\u2009876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n\u2009=\u200961) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P\u2009<\u2009.001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias.\nCONCLUSIONS AND RELEVANCE: Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.', 'publication': 'JAMA'}]
|
limited
|
may be appropriate
|
may be appropriate (disagreement)
|
usually appropriate
|
usually not appropriate
|
D
|
Assess how appropriate it would be to perform a Red Blood Cells scan abdomen and pelvis on a patient with the following characteristics: adult. Endoscopy confirms nonvariceal upper gastrointestinal bleeding without a clear source. Initial imaging.
|
may be appropriate
|
[{'PMID': 23789659, 'Study Quality': '4', 'title': 'Multiphase CT enterography evaluation of small-bowel vascular lesions.', 'abstract': 'OBJECTIVE: By use of multiphase CT enterography (CTE), small-bowel vascular lesions associated with gastrointestinal bleeding can be classified into three categories--angioectasias, arterial lesions, and venous abnormalities--on the basis of common morphology and enhancement patterns. This article will review the unique patterns of enhancement and lesion morphology seen on multiphase CTE and how those findings enable detection and characterization of specific lesions in many cases.\nCONCLUSION: Because of the high prevalence in nonbleeding patients and frequent multiplicity of angioectasias, determining the clinical benefit from their detection by multiphase CTE and endoscopy is problematic. Although arterial lesions are less commonly encountered clinically, their detection is critically important because of a high risk of life-threatening bleeding. Along with wireless capsule endoscopy and balloon-assisted endoscopy, multiphase CTE is a useful tool for the evaluation of patients with obscure gastrointestinal bleeding due to small-bowel vascular lesions.', 'publication': 'AJR Am J Roentgenol'}]
|
expert consensus
|
may be appropriate
|
may be appropriate (disagreement)
|
usually not appropriate
|
usually appropriate
|
A
|
Measure the appropriateness of undertaking a Ultrasound echocardiography transesophageal on a patient with the following characteristics: known or suspected congenital heart disease in the adult.
|
usually appropriate
|
[{'PMID': 2044558, 'Study Quality': '4', 'title': 'The role of transoesophageal echocardiography in adolescents and adults with congenital heart defects.', 'abstract': "Between April 1985 and December 1989, outpatient transoesophageal echocardiography was performed in 133 adolescent and adult patients (14% of all outpatient transoesophageal studies) (age range 11-78 years; weight 30-95 kg) to determine the value of this technique both in establishing the primary diagnosis (62 patients) and in the post-surgical follow up (71 patients) of congenital heart disease. The results were correlated with the findings of precordial echocardiography, catheterization and surgical inspection. Clear advantages of transoesophageal imaging over precordial imaging include: (1) direct identification of atrial appendage morphology in all patients; (2) delineation of systemic and pulmonary venous connections; (3) atrial baffle function (eight patients); (4) better evaluation of the Fontan-type circulation (five patients); (5) improved morphologic assessment of the atrioventricular junction and valves (29 patients); (6) definition of subaortic obstruction (18 patients); and (7) definition of ascending aortic morphology in Marfan's syndrome and supravalvar aortic stenosis (13 patients). The problems encountered with transoesophageal imaging include: (1) limited imaging planes; (2) poor visualization of specific intracardiac regions (antero-apical trabecular septum, right ventricular outflow tract); (3) flow masking behind implanted intracardiac prosthetic material.", 'publication': 'Eur Heart J'}, {'PMID': 26088383, 'Study Quality': '3', 'title': 'Comprehensive assessment of morphology and severity of atrial septal defects in adults by CT.', 'abstract': 'BACKGROUND: Cardiac CT is an excellent tool for evaluating the anatomy of a secundum atrial septal defect (ASD). However, a comprehensive assessment of its usefulness, including measurement of the pulmonary to systemic blood flow ratio in secundum ASD patients, has not been performed.\nOBJECTIVE: Therefore, this study was designed to evaluate the usefulness of CT for assessing the hemodynamics of secundum ASD in adults compared with transesophageal echocardiography (TEE), transthoracic echocardiography, and invasive catheterization.\nMETHODS: Fifty adult patients with secundum ASD were enrolled. Cardiac CT scans (128-slice multidetector CT instrument) were acquired. These were followed by 2-dimensional reconstruction of the secundum ASDs to determine the defect size, the rim length between the outer edge of the defect, and the pulmonary to systemic blood flow (Qp/Qs) ratio.\nRESULTS: The maximum sizes of the secundum ASDs derived from CT and TEE studies were comparable (21.2 ± 8.0 vs. 20.0 ± 7.3 mm; P = .41; r = 0.960; P < .001). The rim lengths for the aortic, mitral, and tricuspid valves; the inferior vena cava; and posterior atrium were also comparable between CT and TEE measurements. The mean Qp/Qs ratio that was derived from CT measurements was comparable with that found by invasive catheterization (2.3 ± 0.7 vs. 2.3 ± 0.8; P = .73; r = 0.786; P < .001).\nCONCLUSION: Cardiac CT is feasible for assessing pathology and the severity of secundum ASD in adults.', 'publication': 'J Cardiovasc Comput Tomogr'}, {'PMID': 24554131, 'Study Quality': '4', 'title': 'Recommendations for transoesophageal echocardiography: EACVI update 2014.', 'abstract': 'With this document, we update the recommendations for transoesophageal echocardiography (TOE) of the European Association of Cardiovascular Imaging. The document focusses on the areas of interventional TOE, in particular transcatheter aortic, mitral, and left atrial appendage interventions, as well as on the role of TOE in infective endocarditis, adult congenital heart disease, and aortic disease.', 'publication': 'Eur Heart J Cardiovasc Imaging'}, {'PMID': 1999032, 'Study Quality': '2', 'title': 'Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations.', 'abstract': "BACKGROUND: During the past few years, transesophageal echocardiography (TEE) has been increasingly used in clinical cardiology; data concerning the practicability and safety of the technique, however, are rare.\nMETHODS AND RESULTS: This report analyzes the experience of 15 European centers performing TEE studies for at least 1 year. At the time of this survey, 10,419 TEE examinations had been attempted or performed in these institutions. These TEE examinations were carried out by 54 physicians, 53.7% of whom had been trained in endoscopic techniques. Within the same time period, 160,431 precordial echocardiographic examinations were performed in the 15 institutions; the ratio between TEE and transthoracic studies averaged 9.03 +/- 6.4% (range of the 15 centers, 1.4-23.6%). Of the 10,419 patients, 9,240 (88.7%) were conscious inpatients or outpatients at the time of the TEE examination; the vast majority of the conscious patients did not receive intravenous sedation before TEE. In 201 cases (1.9%), insertion of the TEE probe was unsuccessfully attempted because of a lack of patient cooperation and/or operator experience (98.5%) or because of anatomical reasons (1.5%). In 90 of 10,218 TEE studies (0.88%) with successful probe insertion, the examination had to be interrupted because of the patient's intolerance of the echoscope (65 cases); because of pulmonary (eight cases), cardiac (eight cases), or bleeding complications (two cases); or for other reasons (seven cases). One of the bleeding complications resulted from a malignant lung tumor with esophageal infiltration and was fatal (mortality rate, 0.0098%).\nCONCLUSIONS: This multicenter survey documents that TEE studies are associated with an acceptable low risk when used by experienced operators under proper safety conditions.", 'publication': 'Circulation'}]
|
moderate
|
usually appropriate
|
may be appropriate (disagreement)
|
usually not appropriate
|
may be appropriate
|
A
|
Gauge the appropriateness of executing a Magnetic Resonance Imaging breast without Intravenous contrast on a patient with the following characteristics: newly diagnosed. Clinical stage I-IIA (early stage) breast cancer at presentation. Evaluation for locoregional disease (includes invasive ductal carcinoma [IDC], or invasive lobular carcinoma [ILC], or not otherwise specified [NOS]).
|
usually not appropriate
|
[{'PMID': 22751517, 'Study Quality': '4'}]
|
expert consensus
|
may be appropriate
|
usually not appropriate
|
may be appropriate (disagreement)
|
usually appropriate
|
B
|
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