Evidence-Based Imaging (eBook)

Dr. Santiago Medina joined Miami Children's Hospital as a neuroradiologist and pediatric radiologist in 1999 . He received his medical degree from the Institute of Health Sciences, CES University in Colombia and a master’s degree in public health and health care management from Harvard School of Public Health, Massachusetts. Dr. Medina’s medical training includes a medical and surgical internship in Medellin General Hospital, Colombia, and a radiology residency at Mallinckrodt Institute of Radiology - Washington University Medical Center in Missouri, as well as a pediatric radiology fellowship and a neuroradiology fellowship at Boston Children’s Hospital and affiliated Harvard Medical School Hospitals in Massachusetts. Dr. Santiago Medina is co-founder and director of MCH’s Health Outcomes, Policy and Economics (HOPE) Center and co-director of the Division of Neuroradiology in the Department of Radiology. He is a member of several professional committees and gives multiple lectures on evidence-based medicine and central nervous system imaging . Dr. Santiago Medina has published numerous articles in national and international peer review journals . He is bi-lingual in English and Spanish.

Foreword 8
Preface 10
Contents 12
Contributors 16
Part I Principles, Methodology, Economics, and Radiation Risk 22
1: Principles of Evidence-Based Imaging 23
I. What Is Evidence-Based Imaging? 23
II. The Evidence-Based Imaging Process 25
A. Formulating the Clinical Question 25
B. Identifying the Medical Literature 25
C. Assessing the Literature 25
1. What Are the Types of Clinical Studies? 26
2. What Is the Diagnostic Performance of a Test: Sensitivity, Specificity, and Receiver Operating Characteristic Curve? 27
3. What Are Cost-Effectiveness and Cost-Utility Studies? 29
D. Types of Economic Analyses in Medicine 29
E. Summarizing the Data 31
F. Applying the Evidence 31
III. How to Use This Book 34
IV. Take Home Appendix 1: Equations 35
V. Take Home Appendix 2: Summary of Bayes’ Theorem 35
References 36
2: Critically Assessing the Literature: Understanding Error and Bias 38
Issues 38
I. What Are Error and Bias? 38
II. What Is Random Error? 39
A. Type I Error 39
B. Confidence Intervals 39
C. Type II Error 40
D. Power Analysis 40
III. What Is Bias? 40
IV. What Are the Inherent Biases in Screening? 42
V. Qualitative Literature Summary 42
Conclusion 43
Take Home Tables and Figures 43
References 45
3: Radiation Risk from Medical Imaging: A Special Need to Focus on Children 46
Key Points 47
Definition and Pathophysiology 47
Radiation Terminology 47
Radiation Mechanisms of Effect 47
Types of Biological Effects 48
Radiation Doses in Medical Imaging 48
Epidemiology and Medical Utilization of Ionizing Radiation 48
Increased Dose from Medical Imaging 49
Increased Use of CT Scans 49
Assessing Risk Versus Benefit when Using Medical Imaging in Children 49
Overall Cost to Society 50
Goals 50
Methodology 50
I. Is There a Cancer Risk from Low-Level Radiation Used in Medical Imaging? What Are the Uncertainties in the Data? 51
A. Cancer Risk and Radiation Following Diagnostic Medical Imaging 51
B. CT Scan and Risk 51
C. Assumptions in Estimating Radiation Risks 52
D. Increased Radiosensitivity in Children 52
E. Nonfatal Cancers 52
F. Additional Confounders in Risk Estimation 52
G. Radiation Doses from Medical Imaging and Uncertainty in Cancer Risks 52
II. What Is the Estimated Risk from a Single Chest X-Ray in a Child? 53
III. What Is the Estimated Risk from a Single Abdominal CT Scan in a Child? 53
A. The Changing Landscaping of Radiation Dose for Medical Imaging 54
B. Lowering CT Dose in Children 54
IV. Understanding Benefit Versus Risk of Imaging Tests in Well-Indicated Studies Versus Those that Have Very Low Probability 54
A. The Example of CT in Children with Headache 54
V. How Should I Communicate Radiation Risk from Imaging to Parents and Patients? 55
VI. Special Situation: Increased Cancer Risk Following Therapeutic Medical Radiation 56
Take Home Tables and Figures 56
Future Research 56
References 60
4: The Economic and Regulatory Impact of Evidence-Based Medicine on Radiology 61
Issues 61
Key Points 61
I. What Political and Economic Forces Influence the United States’ Healthcare System? 62
II. What Is the Impetus Driving US Healthcare Reform Now? 63
III. How Are Rising Costs of Healthcare Affecting Governments and Individuals? 63
IV. Do Increased Health Expenditures Lead to Better Care? 65
V. How Does Supplier-Driven Demand Influence Imaging Utilization? 66
VI. What Can Be Learned from “High-Value” Systems? 66
VII. Cost-Control Strategies: Rationing Versus Reducing Inappropriate Care 67
A. Reimbursement Cuts 67
B. Intermediaries (RBM Organizations) 68
C. Accountable Care Organizations 69
VIII. How Is the Recently Passed US Healthcare Reform Initiative Expected to Influence Cost and Quality? 70
A. Learning What Works 70
B. Coming Changes 71
C. Political Outlook 71
IX. What Are the Challenges and Opportunities for Evidence-Based Imaging? 71
Take Home Tables and Figures 73
References 74
Part II Oncologic Imaging 76
5: Breast Imaging 77
Issues 77
Mammography Screening 77
Breast Ultrasound 77
Diagnosis of Nonpalpable Breast Cancer by Percutaneous Image-Guided Biopsy 77
Mammography 78
Ultrasound 78
Biopsy 78
Pathophysiology and Epidemiology 79
Overall Cost to Society 80
Goals 80
Methodology 80
I. How Effective Is Mammographic Screening? 80
II. Who Should Undergo Screening? 82
III. How Frequently Should Women Be Screened? 83
IV. How Cost-Effective Is Mammographic Screening? 84
V. How Should Ultrasound Be Applied to Breast Cancer Screening? 84
VI. How Accurate Is Ultrasound in Evaluating Palpable Breast Masses? 85
VII. How Accurate Is Ultrasound in Evaluating Nipple Discharge? 86
VIII. How Accurate Is Ultrasound in Determining Local Extent of Disease? 86
IX. Which Lesions (BIRADS 1–6) Should Undergo Biopsy? 87
A. Special Case: Radial Sclerosing Lesions (Radial Scars) 87
X. What Is the Performance of Percutaneous Image-Guided Breast Biopsy Compared with Standard Surgical Excisional Biopsy? 87
XI. What Type of Imaging Guidance Is Best Suited for Breast Lesions that Manifest as Masses or as Microcalcifications? 88
A. Special Case: Biopsy of Breast Lesions Detected on Breast MRI 88
XII. How Cost-Effective Is Image-Guided Biopsy? 89
Take Home Tables and Figures 89
Future Research 101
References 101
6: Imaging of Lung Cancer 105
Issues 105
Key Points 105
Definition and Pathophysiology 105
Epidemiology 106
Overall Cost to Society 106
Goals 106
Methodology 106
I. Is There a Role for Imaging in Lung Cancer Screening? 107
A. What Is the Role of Chest X-Ray? 107
B. What Is the Role of Computed Tomography? 108
Will Computed Tomography Screening Be Cost-Effective? 110
II. How Should Lung Cancer Be Staged? 111
A. How Is the Primary Tumor Evaluated? 111
B. How Is the Mediastinum Evaluated? 111
C. How Are Distant Metastases Evaluated? 112
Pleural Effusion 112
Liver Metastasis 112
Adrenal Metastasis 112
Bone Metastasis 112
Cerebral Metastasis 113
D. Special Case: How Is Small Cell Lung Cancer Evaluated? 113
E. Special Case: What Is the Appropriate Radiologic Follow-Up? 113
Suggested Imaging Protocols 115
Low-Dose Screening Computed Tomography 115
Chest Computed Tomography for Lung Cancer Staging 115
Take Home Tables and Figures 115
Future Research 119
References 119
7: Imaging-Based Screening for Colorectal Cancer 124
Issues 124
Key Points 124
Definition and Pathophysiology 125
Epidemiology 125
Overall Cost to Society 125
Goals 125
Methodology 125
I. Who Should Undergo Colorectal Screening? 126
A. Fecal Occult Blood Testing 126
B. Sigmoidoscopy 126
C. Combined Sigmoidoscopy and FOBT 127
D. Colonoscopy 127
II. What Imaging-Based Screening Methods Are Available, and How Do They Compare with FOBT, Sigmoidoscopy, and Colonoscopy? 128
A. Double Contrast Barium Enema 128
B. Computed Tomographic Colonography 128
C. Special Case: Patients with Increased Risk of CRC 129
Family History of CRC or Adenomatous Polyps 130
D. Special Case: Patients with High Risk of CRC 131
Familial Adenomatous Polyposis 132
III. What Is the Role of Imaging in Staging Colorectal Carcinoma? 132
IV. Applicability to Children 133
V. Cost-Effectiveness 133
VI. What Imaging-Based Screening Developments Are on the Horizon that May Improve Compliance with Colorectal Screening? 134
Take Home Tables and Figures (Tables 7.1–7.3) 134
Imaging Case Studies 134
Case 1: False-Negative CTC (Fig. 7.1) 135
Case 2: False-Positive CTC (Fig. 7.2) 135
Case 3: True-Positive CTC and Colonoscopy (Fig. 7.3) 135
Case 4: True-Positive CTC and False-Negative Colonoscopy (Fig. 7.4) 135
Suggested Imaging Protocol for Asymptomatic Screening Patients 135
Future Areas of Research 139
References 139
8: Imaging of Brain Cancer 142
Issues 142
Key Points 142
Definition and Pathophysiology 143
Unique Challenges of Brain Cancer 143
Epidemiology 143
Adult Brain Cancer 143
Pediatric Brain Cancer 144
Overall Cost to Society 145
Goals 145
Methodology 145
I. Who Should Undergo Imaging to Exclude Brain Cancer in Adult Individual? 146
IIA. Who Should Undergo Imaging to Exclude Brain Cancer in Pediatric Age Group? 146
IIB. What Imaging Is Appropriate in High-Risk Pediatric Subjects? 147
Nuclear Medicine Imaging Tests 148
III. What Is the Appropriate Imaging in Subjects at Risk for Brain Cancer? 148
Special Case: Neuroimaging Differentiation of Post-treatment Necrosis from Residual Tumor 149
Special Case: Neuroimaging Modality in Patients with Suspected Brain Metastatic Disease 149
Special Case: How Can Tumor Be Differentiated from Tumor-Mimicking Lesions? 150
IV. What Is the Role of Proton Magnetic Resonance Spectroscopy in the Diagnosis and Follow-Up of Brain Neoplasms? 150
V. Can Imaging Be Used to Differentiate Post-treatment Necrosis from Residual/Recurrent Tumor? 151
VI. What Is the Added Value of Functional MRI in the Surgical Planning of Patients with Suspected Brain Neoplasm or Focal Brai 152
VII. What Is the Cost-Effectiveness of Imaging in Patients with Suspected Primary Brain and Disease? 152
Take Home Tables and Figures (Figs. 8.1–8.6 Tables 8.1–8.5)153
Future Research 160
References 160
9: Imaging in the Evaluation of Patients with Prostate Cancer 162
Issues 162
Key Points 162
Definition and Pathophysiology 163
Epidemiology 163
Overall Cost to Society 163
Goals 163
Methodology 163
I. Is Transrectal Ultrasound Valuable as a Prostate Cancer Screening Tool? 163
II. Is Transrectal Ultrasound Useful to Guide Prostate Biopsy? 165
III. Is Imaging Accurate for Staging Prostate Cancer? 166
A. Ultrasound 166
B. Computed Tomography Scan 167
C. Magnetic Resonance Imaging 168
D. Magnetic Resonance Spectroscopic Imaging 169
E. Positron Emission Tomography 170
IV. How Accurate Is Bone Scan for Detecting Metastatic Prostate Cancer? 171
A. Special Case: Which Patients Should Undergo Imaging After Initial Treatment to Look for Metastatic Disease? 172
Take Home Figures 172
Imaging Case Studies 172
Case 1 172
Case 2 173
Imaging Protocols Based on the Evidence 174
Transrectal Ultrasound 174
Computed Tomography 174
Magnetic Resonance Imaging 174
Radionuclide Bone Scan 174
Positron Emission Tomography Scan 175
Future Research 175
References 175
Part III Neuroimaging 179
10: Neuroimaging in Alzheimer Disease 180
Issues 180
Key Points 180
Definition and Pathophysiology 181
Epidemiology 181
Overall Cost to Society 181
Goals 181
Methodology 182
I. How Accurate Are the Clinical Criteria for the Diagnosis of Alzheimer Disease? 182
II. Does Neuroimaging Increase the Diagnostic Accuracy of Alzheimer Disease in the Clinical Setting? 183
A. Structural Neuroimaging 183
1. Special Case: Volumetric Measurements 183
B. Functional Neuroimaging 184
C. Other Magnetic Resonance Techniques 184
III. Can Neuroimaging Identify Individuals at Elevated Risk for Alzheimer Disease and Predict Its Future Development? 185
A. Prodromal Alzheimer Disease, or Mild Cognitive Impairment 185
B. Asymptomatic Apolipoprotein E e4 Carriers 186
IV. Is Neuroimaging Cost-Effective for the Clinical Evaluation of Alzheimer Disease? 186
V. Can Neuroimaging Measure Disease Progression and Therapeutic Efficacy in Alzheimer Disease? 187
Take Home Tables (Tables 10.1 and 10.2) 188
Suggested Protocols 188
Computed Tomography Imaging 188
Magnetic Resonance Imaging 188
Fluorodeoxyglucose-PET and SPECT Imaging 188
Future Research Areas 193
References 193
11: Neuroimaging in Acute Ischemic Stroke 196
Issues 196
Key Points 196
Definition and Pathophysiology 197
Epidemiology 197
Overall Cost to Society 197
Goals 197
Methodology 198
I. What Is the Imaging Modality of Choice for the Detection of Intracranial Hemorrhage? 198
A. Computed Tomography 198
B. Magnetic Resonance Imaging 199
II. What Are the Imaging Modalities of Choice for the Identification of Brain Ischemia and the Exclusion of Stroke Mimics? 200
A. Computed Tomography 200
B. Magnetic Resonance Imaging 201
III. What Imaging Modality Should Be Used for the Determination of Tissue Viability: The Ischemic Penumbra? 202
A. Magnetic Resonance Imaging 202
B. Computed Tomography 203
C. Positron Emission Tomography 204
D. Single Photon Emission Computed Tomography (SPECT) 204
IV. What Is the Role of Noninvasive Intracranial Vascular Imaging? 205
A. Computed Tomography Angiography 205
B. Magnetic Resonance Angiography 205
V. What Is the Role of Acute Neuroimaging in Pediatric Stroke? 206
Take Home Table 206
Acute Imaging Protocols Based on the Evidence 206
Areas of Future Research 209
References 210
12: Pediatric Sickle Cell Disease and Stroke 212
Issues 212
Key Points 212
Definition, Pathophysiology, and Clinical Presentation 213
Epidemiology of SCD 214
Epidemiology of Stroke 214
Risk of Stroke 215
Epidemiology of Recurrent Stroke 215
Epidemiology of Silent Infarcts Diagnosed by MRI 215
Overall Cost to Society 215
Cost of Screening 216
Cost-Effectiveness Analysis 216
Goals 216
Methodology 216
I. What Is the Role of Neuroimaging in Acute Stroke in Children with Sickle Cell Disease? 217
CT 217
MRI 217
MRA 217
Angiography 218
Nuclear Medicine (PET, SPECT) 218
II. What Is the Role of Neuroimaging in Children with Sickle Cell Disease at Risk of Their First Stroke? 218
Risk of Symptomatic Stroke in Children with Silent Infarct on MRI 219
III. What Is the Role of Neuroimaging in Prevention of Recurrent Ischemic Stroke in Children with Sickle Cell Disease? 219
IV. Are There Neuroimaging Criteria That Indicate That Blood Transfusions Can Be Safely Halted? 220
V. What Is the Role of Neuroimaging in Hemorrhagic Stroke in Children with SCD? 220
Take Home Figures and Tables 221
Imaging Case Studies 221
Case 1 221
Suggested Imaging Protocol for Sickle Cell Disease and Stroke 223
Future Research 223
References 225
13: Neuroimaging for Traumatic Brain Injury 229
Issues 229
Key Points 229
Definition and Pathophysiology 230
Epidemiology in USA 231
Overall Cost to Society 231
Goals 231
Methodology 231
I. Which Patients with Head Injury Should Undergo Imaging in the Acute Setting? 232
II. What Is the Sensitivity and Specificity of Imaging for Injury Requiring Immediate Treatment/Surgery? 233
III. What Is the Overall Sensitivity and Specificity of Imaging in the Diagnosis and Prognosis of Patients with Head Trauma? 233
Imaging Classification Schemes 234
Normal Scans 235
Brain Swelling 235
Midline Shift 235
Hemorrhage 235
Number, Size, and Depth of Lesions 235
Diffuse Axonal Injury 236
Combinations of Imaging Abnormalities and Progressive Brain Injury 236
Measures of Atrophy 237
Combinations of Clinical and Imaging Findings 237
IV. What Are Considerations for Imaging of Children with Head Trauma? 237
V. What Is the Role of Advanced Imaging (Functional MRI, MR Spectroscopy, Diffusion Imaging, SPECT, and PET) in TBI? 241
Take Home Data 245
Imaging Case Studies 245
Study 1: Example of MR Imaging for TBI 245
Study 2: Example of MR Spectroscopy 245
Suggested Protocols for Acute TBI Imaging 245
Future Research 253
References 253
14: Neuroimaging of Seizures 256
Issues 256
Key Points 256
Definitions 257
Epidemiology 257
Specific Epidemiologic Data 258
Overall Cost to Society 258
Goals 258
Methodology 258
I. Is Neuroimaging Appropriate in Patients with Febrile Seizures? 259
II. What Neuroimaging Examinations Do Patients with Acute Nonfebrile Symptomatic Seizures Need? 259
III. What Is the Role of Neuroimaging in Patients with First Unprovoked Seizures? 259
IV. What Is the Most Appropriate Study in the Workup of Patients with Temporal Lobe Epilepsy of Remote Origin? 261
V. When Should Functional Imaging Be Performed in Seizure Patients and What Is the Study of Choice? 263
Take Home Figure 264
Future Research 264
Imaging Case Studies 265
References 269
15: Adults and Children with Headaches: Evidence-Based Role of Neuroimaging 271
Issues 271
Key Points 271
Definition and Pathophysiology 272
Epidemiology 272
Adults 272
Children 273
Overall Cost to Society 273
Goals 273
Methodology 273
I. Which Adults with New-Onset Headache Should Undergo Neuroimaging? 273
II. What Neuroimaging Approach Is Most Appropriate in High Risk Adults with New-Onset of Headache? 274
III. What Is the Role of Neuroimaging in Adults with Migraine or Chronic Headaches? 274
IV. What Is the Recommended Neuroimaging Examination in Adults with Headache and Known Primary Neoplasm Suspected of Having Br 275
V. When Is Neuroimaging Appropriate in Children with Headache? 276
VI. What Is the Sensitivity and Specificity of CT and MR Imaging for Space Occupying Lesions? 276
VII. What Is the Sensitivity and Specificity of CT and MRI of Imaging in Patients with Headache and Subarachnoid Hemorrhage S 277
VIII. What Is the Role of Advance Imaging Techniques in Primary Headache Disorders? 278
IX. What Is the Cost-Effectiveness of Neuroimaging in Patients with Headache? 279
Take Home Data 279
Imaging Case Studies 280
Study 1: Colloid Cyst 280
Study 2: Chiari I 280
Study 3: Brain Stem Infiltrative Glial Neoplasm 280
Suggested Protocols 280
CT Imaging 280
CT Without Contrast 280
CT with Contrast 280
MR Imaging 280
Future Research 284
References 284
16: Imaging Evaluation of Sinusitis: Impact on Health Outcome 286
Issues 286
Key Points 286
Definition and Pathophysiology 287
Epidemiology 287
Overall Cost to Society 288
Goals 288
Methodology 289
I. Is There a Role for Imaging in the Initial Diagnosis of Acute Bacterial Sinusitis? 289
II. What Is the Diagnostic Performance of Sinus Radiography and Sinus CT in Acute Bacterial Sinusitis? What Diagnostic Criteria 290
III. When Are Imaging Studies Indicated for the Diagnosis and the Management of Patients with Sinusitis? 292
IV. What Is the Most Cost Effective Strategy for the Diagnosis and the Management of Acute Sinusitis? 293
V. What Is the Imaging Role for Patients with Chronic Sinusitis? 294
VI. Special Situation: What Is the Role of Imaging in Immunocompromised Patients? 295
Take Home Tables 296
Imaging Case Studies 297
Suggested Imaging Protocols for Children Clinically Suspected Acute Sinusitis 297
Sinus Radiographs 297
Low Dose Screening Sinus CT 297
MRI 297
Future Research 301
References 301
Part IV Musculoskeletal Imaging 303
17: Imaging of Acute Hematogenous Osteomyelitis and Septic Arthritis in Children and Adults 304
Issues 304
Key Points 304
Definition and Pathophysiology 305
Epidemiology 305
Overall Cost to Society 306
Goals 306
Methodology 306
I. What Are the Clinical Findings that Raise the Suspicion for Acute Hematogenous Osteomyelitis and Septic Arthritis to Direct 306
II. What Is the Diagnostic Performance of the Different Imaging Studies in Acute Hematogenous Osteomyelitis and Septic Arthrit 307
III. What Is the Natural History of Osteomyelitis and Septic Arthritis, and What Are the Roles of Medical Therapy Versus Surgi 308
IV. Is There a Role for Repeat Imaging in the Management? 308
V. What Is the Diagnostic Performance of Imaging of Osteomyelitis and Septic Arthritis in the Adult? 309
VI. What Are the Roles of the Difference Imaging Modalities in the Evaluation of Acute Osteomyelitis and Septic Arthritis? 309
Imaging Case Studies 310
Case 1 310
Case 2 310
Case 3 310
Suggested Imaging Protocols 310
Take Home Tables and Figures 310
Future Research 313
References 313
18: Imaging for Knee and Shoulder Problems 316
Issues 316
Imaging of the Knee 316
Imaging of the Shoulder 316
Key Points 316
Epidemiology 317
Overall Cost to Society 317
Goals 318
Methodology 318
I. What Is the Role of Radiography in Patients with an Acute Knee Injury and Possible Fracture? 318
A. Cost-Effectiveness Analysis 319
B. Applicability to Children 319
II. When Should Magnetic Resonance Imaging Be Used for Patients with Suspected Meniscal or Ligamentous Knee Injuries? 320
A. Cost-Effectiveness Analysis 321
III. Is Radiography Useful in Evaluating the Osteoarthritic Knee? 322
IV. Special Case: Imaging of the Painful Prosthesis 322
V. When Is Radiography Indicated for Patients with Acute Shoulder Pain? 323
VI. Which Imaging Modalities Should Be Used in the Diagnosis of Soft Tissue Disorders of the Shoulder? 324
Take Home Tables and Figures 326
Suggested Imaging Protocols 326
Future Research 331
References 331
19: Pediatric Fractures of the Ankle 334
Issues 334
Key Points 334
Definition and Pathophysiology 335
Epidemiology 335
Overall Cost to Society 335
Goals 335
Methodology 335
I. What Are the Clinical Indications for Obtaining the Ankle X-ray Series Following Trauma in a Child? 335
II. What Is the Diagnostic Performance of Computed Tomography in the Investigation of Ankle Fractures in Children? 336
III. What Is the Diagnostic Performance of Magnetic Resonance Imaging in the Investigation of Ankle Injuries in Children? 337
IV. What Is the Diagnostic Performance of Ultrasound in the Investigation of Ankle Injuries in Children? 337
Take Home Tables 337
Imaging Case Studies 338
Case 1 338
Case 2 338
Suggested Imaging Protocol for Fractures of the Ankle 338
Radiographs 338
CT and MRI 338
Future Research 341
References 341
20: Imaging of Adults with Low Back Pain in the Primary Care Setting 342
Issues 342
Key Points 343
Definition and Pathophysiology 343
Epidemiology and Differential Diagnosis of LBP in Primary Care 344
Overall Cost to Society 345
Goals 345
Methodology 345
I. What Is the Role of Imaging in Patients Suspected of Having a Herniated Disk? 345
A. Plain Radiography 346
B. Computed Tomography 346
C. Magnetic Resonance 346
II. What Is the Role of Imaging in Patients with Low Back Pain Suspected of Having Metastatic Disease? 348
A. Plain Radiographs 348
B. Computed Tomography 348
C. Magnetic Resonance 348
D. Bone Scanning and Single Photon Emission Computed Tomography 349
E. Cost-Effectiveness Analysis 349
III. What Is the Role of Imaging in Patients with Back Pain Suspected of Having Infection? 349
A. Plain Radiographs 349
B. Computed Tomography 350
C. Magnetic Resonance 350
D. Bone Scanning and Single Photon Emission Computed Tomography 350
IV. What Is the Role of Imaging in Patients with Low Back Pain Suspected of Having Compression Fractures? 350
A. Plain Radiographs 350
B. Computed Tomography 350
C. Magnetic Resonance 350
D. Bone Scanning and Single Photon Emission Computed Tomography 351
V. What Is the Role of Imaging in Patients with Back Pain Suspected of Having Ankylosing Spondylitis? 351
A. Plain Radiographs 351
B. Computed Tomography 351
C. Magnetic Resonance 351
D. Bone Scanning and Single Photon Emission Computed Tomography 351
VI. What Is the Role of Imaging in Patients with Back Pain Suspected of Having Spinal Stenosis? 351
A. Plain Radiographs 351
B. Computed Tomography 351
C. Magnetic Resonance 352
D. Bone Scanning and Single Photon Emission Computed Tomography 352
VII. What Are Patients’ Perceptions of the Role of Imaging in Low Back Pain? 352
VIII. What Is the Role of Vertebroplasty for Patients with Painful Osteoporotic Compression Fractures? 353
Overall Modality Accuracy Summary 353
Suggested Imaging Protocols 354
Plain Radiographs 354
Computed Tomography 354
Magnetic Resonance 354
Take Home Tables and Figures 354
Future Research 360
References 361
21: Imaging of the Spine in Victims of Trauma 363
Issues 363
Key Points 363
Definition and Pathophysiology 364
Epidemiology 364
Overall Cost to Society 364
Goals 364
Methodology 365
I. Who Should Undergo Cervical Spine Imaging? 365
A. NEXUS Prediction Rule 365
B. Canadian Cervical Spine Prediction Rule 365
C. Applicability to Children 366
II. What Cervical Spine Imaging Is Appropriate in High-Risk Patients? 366
A. Cost-Effectiveness Analysis 367
III. Special Case: Defining Patients at High Fracture Risk 368
A. Applicability to Children 368
IV. Special Case: The Unconscious Patient 368
V. Who Should Undergo Thoracolumbar Spine Imaging? 369
A. Applicability to Children 369
VI. Which Thoracolumbar Imaging Is Appropriate in Blunt Trauma Patients? 369
Take Home Tables and Figures 370
Future Research 373
Suggested Imaging Protocols 373
References 373
22: Imaging of Spine Disorders in Children: Dysraphism and Scoliosis 375
Issues 375
Spinal Dysraphism 375
Scoliosis 375
Key Points 375
Spinal Dysraphism 375
Scoliosis 376
Definition and Pathophysiology 376
Spinal Dysraphism 376
Scoliosis 376
Conus Medullaris Position 377
Epidemiology 377
Spinal Dysraphism 377
Scoliosis 377
Goals 378
Spinal Dysraphism 378
Scoliosis 378
Methodology 378
I. How Accurate Is Imaging in Occult Spinal Dysraphism? 378
II. What Are the Clinical Predictors of OSD? 378
III. What Are the Natural History and Role of Surgical Intervention in Occult Spinal Dysraphism? 379
IV. What Is the Cost-Effectiveness of Imaging in Children with Occult Spinal Dysraphism? 379
V. How Should the Radiographic Evaluation of Scoliosis Be Performed? 380
VI. What Radiation-Induced Complications Result from Radiographic Monitoring of Scoliosis? 380
VII. What Is the Role of Magnetic Resonance Imaging in Idiopathic Scoliosis? 381
Take Home Figures and Tables 383
How Should Physicians Evaluate Newborns with Suspected Occult Spinal Dysraphism? 383
How Should Scoliosis Be Evaluated? 383
Imaging Case Studies 383
Case 1: Spinal Dysraphism 383
Case 2: Scoliosis 383
Suggested Imaging Protocols 383
Spinal Dysraphism 383
Spinal Ultrasound 383
Entire Spine MRI 383
Scoliosis 383
Scoliosis Radiographs 383
Entire Spine MRI 383
Future Research 388
References 388
Part V Cardiovascular and Chest Imaging 390
23: Imaging of the Solitary Pulmonary Nodule 391
Issues 391
Key Points 392
Definition and Pathophysiology 392
Epidemiology 393
Overall Cost to Society 393
Goals 393
Methodology 393
I. Who Should Undergo Imaging? 393
A. Nodule Stability in Size 394
B. Nodule Morphology: Calcification 394
C. Nodule Morphology: Fat 395
D. Nodule Morphology: Feeding Artery and Draining Vein 395
E. Nodule Morphology: Rounded Atelectasis 395
F. Applicability to Children 395
II. Which Imaging Is Appropriate? 396
A. Computed Tomography Densitometry 396
B. Thin-Section Computed Tomography 396
C. Computed Tomography Contrast Enhancement 397
D. Dual-Energy Computed Tomography 397
E. Positron Emission Tomography 397
F. Single Photon Emission Computed Tomography 398
G. Percutaneous Needle Biopsy 398
H. Cost-Effectiveness 399
III. Special Case: Estimating the Probability of Malignancy in Solitary Pulmonary Nodules 400
IV. Special Case: Solitary Pulmonary Nodule in a Patient with a Known Extrapulmonary Malignancy 401
Take Home Tables and Figures 402
Future Research 412
References 412
24: Cardiac Evaluation: The Current Status of Outcomes-Based Imaging 414
Issues 414
Key Points 414
Definition and Pathophysiology 415
Epidemiology 415
Overall Cost to Society 415
Goals 415
Methodology 416
I. Does Coronary Artery Calcification Scoring Predict Outcome? 416
II. Special Case: High-Risk Patients 417
III. Which Patients Should Undergo Coronary Angiography? 417
IV. Which Patients Should Undergo Noninvasive Imaging of the Heart? 419
V. What Is the Appropriate Use of Coronary Artery Computed Tomography and Magnetic Resonance? 420
Recommended Imaging Protocols Based on the Evidence 421
Cardiac Catheterization 421
Stress Echo 421
Cardiac SPECT 422
Take Home Figures 422
Future Research 426
References 426
25: Imaging in the Evaluation of Pulmonary Embolism 428
Issues 428
Key Points 428
Definition and Pathophysiology 429
Epidemiology 429
Overall Cost to Society 429
Goals 429
Methodology 429
Comment 429
I. What Is the Performance of Various Imaging Modalities in the Evaluation of Pulmonary Embolism? 430
A. Modality 1: Angiography 430
B. Modality 2: Nuclear Ventilation-Perfusion Imaging 430
C. Modality 3: Computed Tomography Pulmonary Angiography (Scanners with Fewer than Four Detectors) 431
D. Modality 4: Multidetector Computed Tomography 431
E. Modality 5: Electron Beam Computed Tomography 432
F. Modality 6: Magnetic Resonance Angiography 432
G. Modality 7: Ultrasound of Lung and Pleura 433
H. Method 8: Echocardiography 433
I. Modality 9: Chest Radiography 433
II. How Can Imaging Modalities Be Combined in the Diagnosis of Pulmonary Embolism? 434
Take Home Tables and Figures 435
Imaging Case Studies 438
Case 1 438
History 438
Imaging 438
Discussion 438
Case 2 439
History 439
Imaging 439
Discussion 439
Protocols Based on the Evidence 440
A. Ventilation/Perfusion Imaging 440
B. Computed Tomography Pulmonary Angiography 440
Future Research 440
References 440
26: Aorta and Peripheral Vascular Disease 442
Issues 442
Key Points 442
Definition, Pathophysiology, and Epidemiology 443
Overall Cost to Society 443
Goals 443
Methodology 444
I. Aorta: What Are the Appropriate Imaging Studies for Suspected Acute Aortic Dissection or Traumatic Rupture? 444
II. Aorta: What Is the Impact and Cost-Effectiveness of Screening for Abdominal Aortic Aneurysms on Mortality from Abdominal 444
III. Aorta: Endovascular Versus Surgical Treatment of Abdominal Aortic Aneurysms: Which Is the Best Choice? 445
IV. Peripheral Vascular Disease: What Are the Appropriate Noninvasive Imaging Studies for Patients with Suspected Peripheral V 446
A. Magnetic Resonance Angiography 446
B. Computed Tomography Angiography 447
V. Special Case: Evaluation of Abdominal Aortic Aneurysms Graft Endoleak 447
VI. Special Case: Evaluation of the Renal Donor 448
VII. Special Case: Evaluation of Renal Artery Stenosis 449
Take Home Tables and Figures 449
Future Research 452
References 452
27: Imaging of the Cervical Carotid Artery for Atherosclerotic Stenosis 453
Issues 453
Key Points 453
Definition and Pathophysiology 454
Epidemiology 454
Overall Cost to Society 455
Goals 455
Methodology 455
I. What Is the Imaging Modality of Choice in Symptomatic Carotid Stenosis? 455
A. Catheter Angiography 456
B. Magnetic Resonance Angiography 457
C. Computer Tomography Angiography 457
D. Doppler Ultrasound 458
II. What Is the Imaging Modality of Choice in Asymptomatic Carotid Stenosis? 458
A. Cost-Effectiveness Analysis 459
III. What Is the Role of Carotid Angioplasty and Stenting? 459
IV. What Is the Role of Physiologic Imaging in Carotid Stenosis and Occlusion? 460
A. Methods of Hemodynamic Assessment 460
B. Association with Stroke Risk 461
C. Cost-Effectiveness Analysis 462
Take Home Tables (Tables 27.1–27.3) 462
Protocols Based on the Evidence 462
Carotid Angiography 462
Doppler Ultrasound 463
Contrast-Enhanced Magnetic Resonance Angiography 463
Computed Tomographic Angiography 463
References 466
28: Blunt Injuries to the Thorax and Abdomen 467
Issues 467
Key Points 467
Definition and Pathophysiology 468
Epidemiology 468
Overall Cost to Society 468
Goals 469
Methodology 469
I. What Imaging Is Appropriate for Patients with Blunt Trauma to the Chest? 469
A. Chest Wall 469
B. Pleura and Lung 469
C. Diaphragm 470
II. What Imaging Is Appropriate for Patients with Blunt Trauma to the Abdomen? 470
A. Spleen and Liver Injuries 471
B. Bowel and Mesentery Injuries 471
III. What Is the Optimal Imaging Approach in Patients Suspected of Having Retroperitoneal Injury? 472
Take Home Figures 474
Imaging Case Studies 474
Case 1 474
Case 2 474
Future Research 476
Suggested Imaging Protocols 476
Trauma Computed Tomography of the Abdomen and Pelvis 476
Trauma Ultrasound 476
References 476
Part VI Abdominal and Pelvic Imaging 480
29: Imaging of Appendicitis in Adult and Pediatric Patients 481
Issues 481
Key Points 481
Definition and Pathophysiology 482
Epidemiology 482
Overall Cost to Society 482
Goals 482
Methodology 482
I. What Is the Accuracy of Imaging for Diagnosing Acute Appendicitis in Adults? 482
II. What Is the Accuracy of Diagnostic Imaging in Pediatric Patients? 483
III. Which Subjects Suspected of Having Appendicitis Should Undergo Imaging? 485
IV. What Is the Effect of Imaging on Negative Appendectomy Rate? 486
Take Home Tables and Figures 486
Imaging Case Studies 486
Case 1 486
Case 2 487
CT Protocols for Suspected Appendicitis 487
Future Research 489
References 489
30: Imaging in Non-appendiceal Acute Abdominal Pain 490
Issues 490
Key Points 490
Definition and Pathophysiology 491
Epidemiology 491
Overall Cost to Society 492
Goals 492
Methodology 492
Methodology A: Imaging in Small Bowel Obstruction 492
Methodology B: Imaging in Acute Diverticular Disease 492
I. What Is the Accuracy of Imaging for Diagnosing Small Bowel Obstruction? 493
IIA. What Is the Accuracy of Imaging for Acute Colonic Diverticulitis? 494
IIB. What Is the Accuracy of CT in Predicting the Success of Conservative Management in Patients with Suspected Acute Colonic 495
Take Home Tables (Tables 30.1–30.3) 495
Imaging Case Studies 495
Case 1 495
Case 2 495
Suggested Protocols 496
Future Inquiry 496
References 499
31: Intussusception in Children: Diagnostic Imaging and Treatment 500
Issues 500
Key Points 500
Definition and Pathophysiology 501
Epidemiology 501
Rotavirus Vaccine 502
Overall Cost to Society 502
Goals 502
Methodology 502
I. What Are the Clinical Predictors of Intussusception? What Are the Clinical Predictors of Reducibility and Bowel Necrosis? Wh 502
What Are the Clinical Predictors of Intussusception? 503
What Are the Clinical Predictors of Reducibility and Bowel Necrosis? 503
II. Which Imaging Studies Should Be Performed? 503
What Is the Diagnostic Performance of Abdominal Radiographs? 503
What Is the Diagnostic Performance of Sonography? 504
What Are the Sonographic Predictors of Reducibility and Bowel Necrosis? 504
What Are the Pathologic Lead Points? 505
III. How Should Therapeutic Enema Be Performed? 505
Air Versus Liquid Enema 505
The Rule of Threes 506
Radiation Dose 506
Alternative Enema Approaches 506
Fluoroscopy Versus Sonography 507
Delayed Repeat Enema 507
Where Should Patients Be Treated? 507
What Are the Complications of Enema Therapy? 507
What Are the Surgical Management and Complications? 508
Cost-Effectiveness Analysis 508
IV. What Is Appropriate Management in Recurrent Cases? 508
V. Special Case: Intussusception Limited to the Small Bowel 509
VI. Special Case: Intussusception with a Known Lead Point Mass 509
Take Home Tables 509
Imaging Case Study 509
Case 1 509
Suggested Imaging Protocol for Intussusception in Children 510
Ultrasound for Clinically Suspected Intussusception 510
Air Enema for Reduction 510
Future Research Studies 512
References 512
32: Imaging of Infantile Hypertrophic Pyloric Stenosis 514
Definition, Clinical Presentation, and Pathophysiology 515
Issues 514
Key Points 514
Epidemiology 515
Overall Cost to Society 516
Goals 516
Methodology 516
I. What Are the Clinical Findings that Raise the Suspicion for IHPS and Direct Further Investigation? 516
II. What Is the Diagnostic Performance of the Clinical and Imaging Examinations in IHPS? 517
Clinical Palpation 517
Abdominal Radiographs 518
UGI Examination 518
Ultrasound Examination 519
III. Is There a Role for Follow-up Imaging in IHPS? 520
IV. What Is the Natural History of IHPS and Patient Outcome with Medical Therapy Versus Surgical Therapy? 520
Take Home Figures and Tables 521
Imaging Case Studies 521
Case 1 521
Case 2 521
Future Research 523
References 523
33: Imaging of Biliary Disorders: Cholecystitis, Bile Duct Obstruction, Stones, and Stricture 525
Issues 525
Key Points 526
Definition and Pathophysiology 526
Epidemiology 527
Overall Cost to Society 527
Goals 527
Methodology 528
I. What Is the Best Imaging Strategy for the Diagnosis of Acute Calculous Cholecystitis? 528
A. Ultrasonography 528
B. Cholescintigraphy 528
C. Computed Tomography 529
D. Magnetic Resonance Imaging 529
E. Imaging Strategy 529
II. What Is the Best Imaging Strategy for the Diagnosis of Acute Acalculous Cholecystitis? 529
A. Ultrasonography 529
B. Cholescintigraphy 530
C. Computed Tomography 530
D. Imaging Strategy 530
III. What Is the Best Imaging Strategy for the Diagnosis of Chronic Calculous Cholecystitis? 530
A. Ultrasonography 531
B. Cholescintigraphy 531
C. Imaging Strategy 531
IV. What Is the Best Imaging Strategy for the Diagnosis of Chronic Acalculous Cholecystitis? 531
A. Ultrasonography 531
B. Cholescintigraphy 531
C. Endoscopic Retrograde Cholangiopancreatography 532
D. Imaging Strategy 532
V. What Is the Best Imaging Strategy for the Evaluation of Bile Duct Obstruction? 532
A. Ultrasonography 532
B. Computed Tomography 533
C. Magnetic Resonance Cholangiopancreatography 533
D. Endoscopic Ultrasonography 533
VI. What Is the Best Imaging Strategy for the Diagnosis of Choledocholithiasis? 533
A. Ultrasonography 533
B. Computed Tomography 533
C. Endoscopic Retrograde Cholangiopancreatography 534
D. Magnetic Resonance Cholangiopancreatography 534
E. Endoscopic Ultrasonography 534
F. Imaging Strategy 534
VII. What Is the Best Imaging Strategy for the Evaluation of Bile Duct Stricture? 535
A. Ultrasonography 535
B. Computed Tomography 535
C. Endoscopic Retrograde Cholangiopancreatography 536
D. Magnetic Resonance Cholangiopancreatography 536
E. Endoscopic Ultrasonography 536
F. Special Case: Klatskin Tumor 537
G. Imaging Strategy 538
Take Home Tables (Tables 33.4 and 33.5) 538
Future Research 546
References 546
34: Hepatic Disorders: Colorectal Cancer Metastases, Cirrhosis, and Hepatocellular Carcinoma 550
Issues 550
Key Points 550
Definition and Pathophysiology 551
Liver Metastases 551
Cirrhosis and Hepatocellular Carcinoma 551
Epidemiology 552
Liver Metastases 552
Cirrhosis 552
Goals 553
Overall Cost to Society 553
Methodology 553
I. How Accurate Is Imaging in Patients with Suspected Hepatic Metastatic Disease? 553
A. Ultrasonography 554
B. Computed Tomography 554
C. Magnetic Resonance Imaging 555
D. Whole-Body Positron Emission Tomography 556
II. What Is the Accuracy of Imaging in Patients with Cirrhosis for the Detection of Hepatocellular Carcinoma? 556
A. Ultrasonography 557
B. Computed Tomography 557
C. Magnetic Resonance Imaging 558
D. Whole-Body Positron Emission Tomography 558
III. What Is the Cost-Effectiveness of Imaging in Patients with Suspected Hepatocellular Carcinoma? 559
Take Home Tables and Figure (Tables 34.1 and 34.2 Fig. 34.4)560
Imaging Technique Protocols 564
Abdominal Computed Tomography for Detection of Hepatocellular Carcinoma Using Multirow Detector Computed Tomography 564
Liver MRI for Detection of Metastases or Hepatocellular Carcinoma (Minimum Sequences) 564
Future Research 564
References 564
35: Imaging of Inflammatory Bowel Disease in Children 567
Issues 567
Key Points 567
Definition and Pathophysiology 568
Epidemiology and Diagnosis 568
Overall Cost to Society 569
Goals 569
Methodology 569
I. What Are the Important Clinical Predictors of IBD? 570
Laboratory Markers 570
Children Under Age 5 Years 570
II. What Is the Diagnostic Performance of Current Endoscopic Techniques in the Evaluation of Patients with IBD: Lower, Upper En 571
Lower Endoscopy 571
Upper Endoscopy 571
Wireless Capsule Endoscopy 572
III. What Is the Diagnostic Performance of Current Imaging Modalities in Evaluating IBD of the Small Bowel (Small Bowel Follow- 572
Abdominal Radiographs 573
Small Bowel Follow-Through 573
Multidetector CT 573
Enterography 573
Enteroclysis (MR or CT) 574
Ultrasound 575
IV. Complications of IBD (Intra-abdominal Abscess, Intestinal Fistulae, Strictures and Small Bowel Obstruction, Primary Sclero 575
Intra-abdominal Abscess 576
Intestinal Fistulae 576
Strictures and Small Bowel Obstruction 576
Primary Sclerosing Cholangitis 576
V. What Are the Most Important Imaging Features that Lead to Surgery in a Child with Crohn’s Disease and Ulcerative Colitis? 577
Role of Conventional Barium Fluoroscopy and Multidetector CT 577
Role of Enteroclysis (CT/MR) and Enterography (CT/MR) 577
VI. What Are the Role and Risk of Repeat Imaging in Monitoring IBD Response to Treatment? 578
VII. Special Situation: Which Imaging Modality Provides the Best Performance for the Evaluation of Perianal/Perirectal Diseas 579
Take Home Tables and Figures 579
Imaging Case Studies 584
Case 1 584
Case 2 584
Case 3 584
Suggested Imaging Protocols for Inflammatory Bowel Disease in Children 584
Definition of Imaging Techniques 584
Upper Gastrointestinal Study with SBFT UGI/SBFT 584
Enterography (MDCT, MR) 584
Enteroclysis (CT, MR) 584
Wireless Capsule Endoscopy 585
General IBD Algorithm 585
Clinical and Imaging Pathways for CD and UC 585
Future Research 585
References 585
36: Imaging of Nephrolithiasis and Its Complications in Adults and Children 588
Issues 588
Imaging of Nephrolithiasis in Adults 588
Imaging of Nephrolithiasis in Children 588
Imaging of Nephrolithiasis in Adults and Children 588
Key Points 589
Nephrolithiasis in Adults 589
Nephrolithiasis in Children 589
Definition and Pathophysiology 589
Epidemiology 589
Overall Cost to Society 590
Goals 590
Methodology 590
I. What Is the Appropriate Test When There Is Clinical Suspicion of Obstructing Ureteral Stone in Adults? 590
II. How Should Stones Be Followed After Treatment in Adults? 591
III. Special Case: The Pregnant Patient 592
IV. What Are the Clinical Findings that Raise the Suspicion for Stones in Children? 592
V. What Is the Diagnostic Performance of the Different Imaging Studies in Nephrolithiasis and Urinary Tract Calculi in the Pedi 593
Abdominal Radiographs 593
Multidetector Computed Tomography 593
Intravenous Urogram 594
Ultrasound 594
KUB Plus US 594
Ultrasound Followed by MDCT for Equivocal Cases 595
Magnetic Resonance Imaging 595
Special Case: Bladder Calculi 595
VI. What Is the Role of Repeat Imaging in Children with Known Stone? In Children with Recurrent Symptoms (Suggesting Obstructin 595
VII. What Is the Natural History of Nephrolithiasis and Urinary Tract Calculi and What Are the Roles of Medical Therapy Versu 596
VIII. Special Case: Will the Stone Pass on Its Own (Adults and Children)? 596
Take Home Tables (Tables 36.1 and 36.2) 597
Imaging Case Studies 598
Case 1: Pediatric 598
Case 2: Pediatric 598
Case 3: Adult 598
Suggested Adult Computed Tomography Imaging Protocols 598
Suggested Pediatric Imaging Protocols 598
Plain Radiograph 598
Ultrasound 598
MDCT 599
MRI 599
Future Research 600
References 600
37: Urinary Tract Infection in Infants and Children 603
Issues 603
Key Points 603
Definitions and Pathophysiology 604
Epidemiology 605
Overall Cost to Society 605
Goals 605
Methodology 606
I. What Is Known About the Natural History of Urinary Tract Infections in Infants and Children? 606
II. What Can Imaging Reveal in the Setting of UTI? 607
Abdominal Radiographs 607
Sonography 607
Intravenous Pyelogram 608
CT and MRI/MR Urography 608
Nuclear Medicine 608
Evaluation for Vesicoureteric Reflux 608
III. What Are Reasonable Imaging Strategies When Caring for a Male Infant or Child with a History of a Febrile Urinary Tract In 609
IV. What Are Reasonable Imaging Strategies When Caring for a Female Infant or Child with a History of a Febrile Urinary Tract I 609
V. Special Case: Postnatal Management of Fetal Hydronephrosis 610
Take Home Tables and Figures 611
Imaging Case Studies 611
Case 1 611
Case 2 611
Case 3 611
Case 4 611
Case 5 611
Suggested Imaging Protocols for Urinary Tract Infections in Infants and Children 624
Future Research 624
References 624
38: Current Issues in Gynecology: Screening for Ovarian Cancer in the Average Risk Population and Diagnostic Evaluation of Postmenopausal Bleeding 628
Issues 628
Key Points 629
Definition and Pathophysiology 629
Epidemiology 629
Ovarian Cancer 629
Endometrial Cancer 630
Overall Cost to Society 630
Ovarian Cancer 630
Endometrial Cancer 630
Goals 631
Screening in Ovarian Cancer 631
Evaluation in Postmenopausal Bleeding 631
Methodology 631
I. Ovarian Cancer Screening: What Is the Role of Biochemical Markers Such as CA 125? 631
II. Ovarian Cancer Screening: What Is the Diagnostic Performance (Accuracy) of Imaging? 632
III. Ovarian Cancer Screening: What Is the Role of Imaging? 633
A. Screening with Gray-Scale Ultrasound Only 633
B. Screening with Ultrasound and Color Doppler Imaging 633
C. Multimodality Approach Using CA 125 and Ultrasound 634
IV. Postmenopausal Bleeding Evaluation: When Should a Woman with PMB Be Referred for Additional Evaluation? 634
V. Postmenopausal Bleeding Evaluation: What Is the Accuracy of Imaging Tests? 635
A. Transvaginal Ultrasonography 635
B. Saline-Infused Hysterosonography 635
C. Hysteroscopy 635
VI. Postmenopausal Bleeding Evaluation: What Is the Role of Imaging? 636
VII. How Should Women on Tamoxifen Therapy Be Evaluated? 636
Take Home Tables and Figures (Tables 38.1 and 38.2 Figs. 38.1–38.4)636
Protocol: Transvaginal Ultrasound 636
Future Research 640
References 640
39: Imaging of Female Children and Adolescents with Abdominopelvic Pain Caused by Gynecological Pathologies 642
Issues 642
Key Points 642
Definition 643
Pathology and Epidemiology 643
Congenital Anomalies 643
Endometriosis 643
Pelvic Inflammatory Disease 643
Adnexal Torsion 644
Abdominopelvic Mass 644
Pregnancy 645
Overall Cost to Society 645
Pelvic Inflammatory Disease 645
Endometriosis 645
Goals 646
Methodology 646
I. What Is the Diagnostic Performance of the Different Imaging Studies for the Diagnosis or Exclusion of Ovarian Torsion? 646
II. What Is the Best Imaging Technique for the Diagnosis of PID? 646
III. What Is the Best Imaging Technique for the Diagnosis of Endometriosis? 647
IV. What Is the Best Technique for the Diagnosis of an Ectopic Pregnancy? 647
Take-Home Tables 647
Imaging Case Studies 648
Case 1 648
Case 2 649
Suggested Imaging Protocols 649
Plain Radiographs 649
Ultrasound 649
Multi-Detector Computed Tomography 649
Magnetic Resonance Imaging 649
Future Research 650
References 650
40: Imaging of Boys with an Acute Scrotum: Differentiation of Testicular Torsion from Other Causes 652
Issues 652
Key Points 652
Definition and Pathophysiology 653
Epidemiology 653
Overall Cost to Society 653
Goals 654
Methodology 654
I. What Are the Clinical Findings that Raise the Suspicion of Testicular Torsion in Children with Acute Scrotal Pain? 654
II. What Is the Diagnostic Performance of the Different Imaging Studies in Children with Acute Scrotal Pain? 654
Doppler Ultrasound 655
Magnetic Resonance Imaging 655
Radionuclide Imaging 655
III. In Cases of Testicular Torsion, Is Manual Reduction Required? 656
Detorsion 656
Take Home Figures and Tables 656
Imaging Case Studies 658
Case 1 658
Suggested Imaging Protocols for Acute Scrotum 659
Ultrasound 659
Manual Detorsion 659
Future Research 659
References 659
Index 15