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Michael Cerasaro

on 24 June 2016

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Transcript of Rads

What to order when:
Brief intro to ACR's Appropriateness Guidelines

Michael A. Cerasaro, PGY 1 364/365

Mitigate patient risk

Streamline diagnostic work-up

Economic implications of [over]-utilization of diagnostic radiology testing.
Case 1:
Previously healthy 56yo woman with new onset memory impairment.
- ED dept. ordered non-contrast CT of head
Ddx: ??
....What if:
46yo, polysubstance abuse - IVDA, meth, BIB friend c/o slowly progressive decline

22yo, lives in college dorm, 3-4 day hx of N/V, photophobia, headaches, lethargy
86yo, with sudden onset memory loss and dysarthria, with left hemiparesis
The Proof in the Pudding:
1. No one actually likes pudding

2. Rad Rule of 10s
- 10% of total health care expenditures
(total expenditure 2014 ~ $3.0T, about $10,000 per person)
- 10% unnecessary/duplicate

3. Slowed growth rate, overall stable utilization
Age, ACA, CYA, Dr. Google, Clinical pressures, ***SELF-REFERRAL***

4. There's at least SOME good news?

Take home points:
Dx: Creutzfeldt-Jakob disease
All cases fatal, 90% mortality w/in 1yr

CT normal in 80% of cases

MRI typically demonstrates restricted diffusion and T2/FLAIR hyperintensities within the bilateral striatum, thalamus, and cortical gray matter.
Case 2:
55yo male presents to ED with diffuse abdominal pain. Currently undergoing peritoneal dialysis.
KUB ordered by ED physician
..Whaaat if:
Current alcoholic, last drink was 2hrs PTA, diffuse pain but more RUQ

26yo female, sexually active

65yo smoker, mid-epigastric pain radiating to back

Adult with poor diet, frequent constipation, intermittent small volume hematochezia noted on TP and on stool
Hey! Over here!
MRI basics:

T1: "anatomic", more approximate look at tissues and structures
w/ Gad: very bright on T1, highlights vascular structures, breakdown of BBB, meninges, tumors/abscesses

FLAIR - allows attenuation of CSF rendering it dark, better distinction btwn CSF and parenchymal edema - especially in PVWM.
DWI: "facilitated vs. restricted diffusion"

ADC: "apparent diffusion coefficient map" - reconstructed image without T2 input, represents actual diffusion - more objectively useful when looking for ischemia.
Take home points:

Dx: Mesenteric ischemia causing bowel infarction and perforation leading to...
1. Pneumatosis intestinalis
2. Presence of portomesenteric venous gas
3. Pneumoperitoneum
Pneumatosis intestinalis may be a benign finding or may be secondary to significant intra-abdominal pathology, such as mesenteric ischemia.

Portomesenteric venous gas has multiple causes, the most serious and most common of which is mesenteric ischemia.

CT is most sensitive test for Pneumatosis intesitinalis. Also helpful for the detection of pneumoperitoneum and portomesenteric venous gas, as well as for elucidating the underlying causal pathology
Case 3:
A 43yo male presents to the ED with new-onset fatigue and dyspnea, intermittent non-productive cough.
ED physician ordered CXR
...but whaaaat if:
HIV pos, cough + sputum, CD4 165. Patient relates pruritus, on exam he has a multi-focal maculopapular rash

Adult male, c/o substernal chest pain radiating to back, 40 pack year smoking history

75yo female with vague chest pain, shoulder pain, dyspnea

27yo male, BIB co-worker after patient started complaining of R-sided CP and dyspnea

Full transcript