Imaging in the evaluation of headache

Neuroimaging of Headache: Indications and Controversies

Headache is a common presenting symptom in the ambulatory setting that often prompts imaging. The increased use and associated health care money spent in the setting of headache have raised questions about the cost-effectiveness of neuroimaging in this setting. Neuroimaging for headache in most cases is unlikely to reveal significant abnormality or impact patient management. In this article, reasons behind an observed increase in neuroimaging and its impact on health care expenditures are discussed. The typical imaging modalities available and various imaging guidelines for common clinical headache scenarios are presented, including recommendations from the American College of Radiology.

Has China's Healthcare Reform Reduced the Number of Patients in Large General Hospitals?

Many studies have shown that the new round of healthcare reform launched by the Chinese government in 2009 has not effectively solved the problem in which patients more readily choose large general hospitals. We aimed to find out if this situation exists in every department of a large general hospital. This study collected the outpatient data of 24 departments for a large general hospital in Beijing. By calculating the average growth rate of outpatients in each department from 2014 to 2019, and the utilization rate of outpatient appointments in different departments in 2020, we found that the average growth rate of outpatients in 4 departments (16.6%) was negative, and the utilization rate of outpatient appointments in 13 departments (54.16%) was less than 80%. This shows that the number of patients in some departments is declining, and that there is an inefficient use of doctor resources. Obviously, this is inconsistent with people's current beliefs. Therefore, it is not entirely true that China's healthcare reform has not reduced the number of patients in large general hospitals. At the same time, the inefficient use of outpatient doctor resources is a phenomenon worthy of attention; if it persists, it will result in significant waste in the healthcare system. We suggest that policy makers and hospital managers in China, and countries similar to China, can attract attention and take measures.

The degree and appropriateness of computed tomography utilization for diagnosis of headaches in Ghana

INTRODUCTION

Headache is a common and sometimes debilitating medical condition. Patients presenting with no neurologic anomaly, nontraumatic primary headache require careful evaluation before neuroimaging. National Guidelines standardizing exploitation of Computed Tomography (CT), the most utilized imaging modality in this clinical scenario, has not been established in Ghana, a developing country with limited healthcare resources. The country has not also adopted existing guidelines such as the National Institute for Health and Care Excellence (NICE) of the United Kingdom or the Appropriateness Criteria (AC) of the American College of Radiologists (ACR). The purpose of this review was to analyze the propensity of CT utilization for diagnosing headaches against the AC of the ACR and discuss some of the socio-economic inferences thereof.

METHODS

This study retrospectively reviewed CT imaging records and clinical data of all patients referred for head CT scans between 1st January 2016 and 31st December 2018 at five major health facilities (four tertiary government hospitals and one private hospital) across Ghana. We isolated all head CT scans performed for the diagnosis of headache for analysis. We analyzed the type of presenting headache, CT findings, gender distribution, pattern of referrals, and head CT appropriateness against the AC of the ACR.

RESULTS

A total of 44,218 patients were referred to the five facilities for head CT secondary to diverse indications for the period. All non-trauma cases were 41.7%; trauma cases were 31.6%, the majority (72.3%) were from road traffic accidents. The majority (64.9%) of trauma casualties were males. A total of 11,806 (26.7%) patients were referred for a head CT scan for the diagnosis of headache. The private hospital recorded the highest referrals for head CT scan for diagnosis of headache. The gender distribution of all headache patients was 57.6% females, and 42.4% were males. The age distribution showed 19.3% were children, 71.2% were adults, and the aged constituted 9.4%. The results showed 2.8% significant cranial CT findings of all reviewed headache patients. Pathological findings among the cohort of children were 0.6%.The sources and pattern of referrals showed 57.3% were from the Outpatient Department, 26.6% from the Emergency Department, in-patients' referrals were 9.4%, and specialist consultation was 7.1%. Analysis of CT scans performed against the AC of the ACR, showed 69.0% of headache patients were likely scanned inappropriately.

CONCLUSIONS

There is a need to implement international best practice guidelines or develop a national neuroimaging policy to protect patients. Unjustified CT utilization for diagnosis of headaches exposes patients to unnecessary ionizing radiation that can instigate cancer and unnecessary expenditure. Head CT scan for some headache patients with normal neurologic findings may be unnecessary in an emerging country like Ghana. Clinicians must, therefore, be discerning in CT scan requests for the diagnosis of headache.

ACR Appropriateness Criteria® Headache

Headache is one of the most common human afflictions. In most cases, headaches are benign and idiopathic, and resolve spontaneously or with minor therapeutic measures. Imaging is not required for many types of headaches. However, patients presenting with headaches in the setting of "red flags" such as head trauma, cancer, immunocompromised state, pregnancy, patients 50 years or older, related to activity or position, or with a corresponding neurological deficit, may benefit from CT, MRI, or noninvasive vascular imaging to identify a treatable cause. This publication addresses the initial imaging strategies for headaches associated with the following features: severe and sudden onset, optic disc edema, "red flags," migraine or tension-type, trigeminal autonomic origin, and chronic headaches with and without new or progressive features. 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.

Consensus Guidelines of the French Society of Neuroradiology (SFNR) on the use of Gadolinium-Based Contrast agents (GBCAs) and related MRI protocols in Neuroradiology

Gadolinium-based contrast agents (GBCAs) are used in up to 35% of magnetic resonance imaging (MRI) examinations and are associated with an excellent safety profile. Nevertheless, two main issues have arisen in the last two decades: the risk of nephrogenic systemic fibrosis and the risk of gadolinium deposition and retention. As a first step, this article reviews the different categories of GBCAs available in neuroradiology, their issues, and provides updates regarding the use of these agents in routine daily practice. Recent advances in MRI technology, as well as the development of new MRI sequences, have made GBCA injection avoidable in many indications, especially in patients with chronic diseases when iterative MRIs are required and when essential diagnostic information can be obtained without contrast enhancement. These recent advances also lead to changes in recommended MRI protocols. Thus, in a second step, this review focuses on consensus concerning brain MRI protocols in 10 common situations (acute ischemic stroke, intracerebral hemorrhage, cerebral venous thrombosis, multiple sclerosis, chronic headache, intracranial infection, intra- and extra-axial brain tumors, vestibular schwannoma and pituitary adenoma). The latter allowing the standardization of practices in neuroradiology. Recommendations were also made concerning the use of GBCAs in neuroradiology, based on evidence in the literature and/or by consensus between the different coauthors.

Neuroimaging of Adults with Headache: Appropriateness, Utilization, and an Economical Overview

One of the most common reasons that a patient seeks out a health care provider for a neuroscience-related issue is headache. Not all patients can, or probably should, be imaged with headache. We must use an approach that attends to scientific evidence, accepted guidelines, and available resources. This approach should focus on quality, safety, appropriateness, and utilization. This article reviews and discusses the consideration of imaging adult patients with headache.

Unnecessary Neuroimaging for Patients With Primary Headaches

Background - Headache may be due to either a primary or secondary disorder, and neuroimaging assessments can play an important role when differentiating between these types of headache. Although many studies have reported no significant differences between primary headache patients and the general population in terms of abnormal neuroimaging findings, others have shown that neuroimaging may be employed to rule out secondary causes of headache that could impact morbidity and mortality. This issue remains under debate. Thus, the present study compared the neuroimaging findings of headache patients and healthy controls. Methods - This study recruited 1070 healthy controls and 1070 primary headache patients from the Chinese People's Liberation Army General Hospital. The primary headache patients were diagnosed by computerized clinical decision support systems, and re-diagnosed by a specialist. All participants were assessed with either computed tomography or magnetic resonance imaging (MRI) scans. The neuroimaging findings were classified as significant abnormalities, non-significant abnormalities, or normal. Results - All the significant abnormalities were found using MRI scans. Significant abnormalities were identified in 4 primary headache patients (0.58%) and 5 healthy controls (0.73%); the rate of significant abnormalities was not significant different between both groups (P > .05). Conclusions - The present study found that neuroimaging was unnecessary for the primary headache patients.

Neurologic complications in critically ill pregnant patients

Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.

Cortical thickness and functional connectivity abnormality in chronic headache and low back pain patients

This study aims to characterize the psychological wellbeing of chronic headache (CH) patients, to identify cortical structural abnormalities and any associations of those abnormalities with resting state functional connectivity (rsFC), and to determine whether such rsFC abnormality is specific to CH patients. Compared with healthy controls (CON_CH ), CH patients suffered from mild depression, sleep disturbances, and relatively poor quality of life. CH patients also exhibited widespread cortical thickness (CT) abnormalities in left premotor (BA6), right primary somatosensory (S1) and right prefrontal (BA10) cortices, as well as in regions of default mode and executive control networks. Using cortical regions with thickness abnormality as seeds, we found cortical region pairs showed strengthened rsFC in CH patients. Using the same seeds, rsFC analysis from chronic low back pain (CLBP) patients and their controls (CON_CLBP ) identified abnormalities in non-overlapping cortical region pairs. Direct comparison of rsFC between CH and CLBP patients revealed significantly differences in thirteen cortical region pairs, including the four identified in CH and CON_CH comparison. Across all three groups (CH, CLBP and CON), the rsFC between left multisensory association area (BA39) and left posterior cingulate cortex (BA23) differed significantly. Eight regions showed CT abnormality in CLBP patients, two of which overlapped with those of CH patients. Our observations support the notion that CH and CLBP pain are pathological conditions, under which the brain develops distinct widespread structural and functional abnormalities. CH and CLBP groups share some similar structural abnormalities, but rsFC abnormalities in several cortical region pairs appear to be pathology-specific. Hum Brain Mapp 38:1815-1832, 2017. © 2017 Wiley Periodicals, Inc.

Neuroimaging in Secondary Headache Disorders

A secondary headache may develop de novo or in patients with a history of primary headaches, and a thorough history and neurological exam often helps to suspect a secondary etiology. The causes of secondary headaches include tumors, vascular etiologies, structural brain disorders, infection, inflammation, and alterations of cerebrospinal fluid pressure dynamics. Computed tomography (CT) is very sensitive for detecting acute hemorrhage but magnetic resonance imaging (MRI) is preferred over a head CT in subacute and non-emergent cases. Obtaining the correct diagnosis may include incorporation of intravenous contrast agents, special imaging sequences, and functional imaging techniques.

What is the use of imaging before referral to an orthopaedic oncologist? A prospective, multicenter investigation

BACKGROUND

Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests.

QUESTIONS/PURPOSES

(1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study?

METHODS

We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan.

RESULTS

There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%-88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p < 0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68-4.69, p < 0.001).

CONCLUSIONS

We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging.

LEVEL OF EVIDENCE

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Effectiveness of Gatekeepers in Determining the Appropriate Use of Brain MRI/MRA Tests

The purpose of the study is to examine whether, among patients who visited hospitals and underwent brain MRI or MRA scan tests, there was a relationship between the existence of clinically significant abnormal findings and the relevance of primary care physicians' referrals. A case-control study was carried out at six teaching hospitals in Japan. We identified cases with significant abnormal MRI/MRA findings from radiologists' reports based on certain explicit criteria and controls with outpatients who underwent MRI/MRA scans but did not have stroke. We also collected clinical data independently from medical records. The findings of 156 cases and 721 controls were collected for the analysis. A multivariate analysis adjusted by age group, sex, and the number of comorbidity factors showed that those who had visited the hospitals after referral were more likely to have significant abnormal findings in their MRI/MRA scan results (odds ratio [OR] = 1.6, 95% CI: 1.1 to 2.4). The present study suggests that referral from gatekeepers such as primary care physicians is effective in determining the appropriate use of brain MRI/MRA tests for hospital outpatients.