Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease There are 2 scenarios described in the literature characterizing pelvic venous obstruction. Primary chronic venous disease describes a phenomenon in which there is obstruction in the pelvic or abdominal veins (eg, May-Thurner) without a prior DVT. Imaging can then be used to identify the cause of obstruction. Secondary chronic venous disease describes a phenomenon in which primary thrombotic events cause a post-thrombotic syndrome. In addition to an occlusive IVC or iliac vein lesion, these cases also show signs of delayed or incomplete recanalization of the pelvic and lower extremity deep veins with extensive intraluminal changes. In both the above types, primary focus should be on anatomy to accurately identify stenosis and occlusion related to outflow obstruction [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Gadolinium-enhanced MRV with contrast seems to be the examination of choice because of the high intravascular enhancement and acquisition of isotropic voxels with a high spatial resolution allowing for evaluation of subtle changes. Three-dimensional volumetric imaging is preferred over MR direct thrombus or time-of-flight subtraction angiography because surrounding soft tissue should be visible to identify causes of stenosis or occlusion [9].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Pascarella and Shortell [6] believe that imaging of IVC and iliac veins when there is a history of persistent venous ulcers or duplex US evidence of iliocaval obstruction. These findings include diffuse venous reflux, nonphasic common femoral vein velocity spectral waveforms, and reduced flow augmentation with distal thigh compression.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler Lower Extremity It is widely agreed upon that duplex US should be the first assessment of the lower extremity venous system [1,9,14]. Duplex US is currently the most common technique because of its noninvasiveness [20].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Duplex US evaluation should additionally include condition of the deep venous system, GSV, SSV, and accessory saphenous veins. Presence and location of clinically relevant perforating veins and extent of possible alternative refluxing superficial venous pathways should also be included in any duplex US evaluation [1].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Though duplex US is widely considered the reference standard in evaluation of DVT, Hua et al [10] demonstrates that invasive preoperative venography is necessary before intervention to clarify the nature of disease and guide therapy. It is difficult to evaluate iliac vein involvement using this modality [73].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. US Duplex Doppler IVC and Iliac Veins Because duplex US is noted as the first assessment of the lower extremity veins, it can also be used as means to determine patency of the IVC and iliac veins. A good quality examination with normal findings may obviate the need for further imaging. However, in some cases, visualization of the IVC and common iliac veins can be limited in some patients because of obesity or artifacts. Spectral waveforms can aid as an indirect means of assessing patency of the iliac veins or IVC. Evaluation of waveforms in the common femoral veins will show loss of respiratory phase variation and exhibit monophasic physiology with severe iliac vein occlusive disease with a high specificity but low sensitivity [74,75].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Variant 8: Iliocaval or lower extremity disease with severe post-thrombotic changes. Treatment. Anticoagulation The role of anticoagulation is most frequently noted in acute DVT [76]. In chronic DVT, anticoagulation also should have a pivotal role. Many patients with prior chronic DVT are at high risk for thrombosis, and these patients should be given therapeutic anticoagulation [77]. Because of the highly thrombotic environment, most of these patients should be given full dose anticoagulation throughout and immediately after recanalization procedures.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Compression Therapy Despite the minimal evidence regarding C2 to C4 disease, there is evidence that compression therapy has value in C5 (preventing ulcer recurrence) and C6 disease (healing ulcers) [15]. Mosti and Partsch [18] demonstrated that 30 to 40 mm Hg inelastic compression is better than elastic bandaging for wound healing. They also showed that for ankle-brachial indices between 0.9 to 0.6, reduced compression to 20 to 30 mm Hg is successful and safe for VLU healing. Velcro inelastic compression was noted to be as good as 3- or 4-layer inelastic bandages. Caution is advised,


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease however, when the ankle-brachial index is <0.6 because it indicates an arterial anomaly needing revascularization [21].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Endovascular Stenting In a randomized trial by Rossi et al [49], iliac vein stenting was shown to improve symptomatology and QoL compared with medical treatment alone. Thus, based on the morbidity of moderate to severe post-thrombotic syndrome and the available clinical studies and experience with iliac vein stenting for post-thrombotic syndrome treatment, endovascular stenting is a useful treatment [15].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Saphenous Vein Ablation There is no relevant literature regarding the use of saphenous ablation in the treatment of iliocaval or lower extremity post-thrombotic changes.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Compression Sclerotherapy There is no relevant literature regarding the use of foam and compression sclerotherapy or cyanoacrylates in the treatment of iliocaval or lower extremity chronic DVT.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Venous Angioplasty When recanalization of femoral and popliteal veins is performed because of chronic post-thrombotic changes, angioplasty is typically the first-line therapy. Stenting of femoral vein below the lesser trochanter and popliteal veins is not routinely performed because of an increased risk of in-stent thrombosis and occlusion [80,81].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Venous Bypass Procedure Surgical iliac vein reconstruction and variations of venous bypass have been reported. Endovascular options, as discussed above, have proven to be a viable alternative. Venous bypasses in the setting of iliocaval and lower extremity venous disease can be performed in situations in which minimally invasive or conservative options are unsuccessful. The clinical success and patency of these bypasses are poor (infrainguinal) and associated with significant postoperative morbidity (suprainguinal surgery). Poor patency is likely due to low velocity through the graft, external compression, inherent thrombus formation, and/or inadequate distal venous inflow [82].


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. Lower Extremity Chronic Venous Disease Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Lower Extremity Chronic Venous Disease

Lower Extremity Chronic Venous Disease. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Chronic Ankle Pain

Chronic Ankle Pain. Introduction/Background Ankle pain is considered chronic when symptoms persist >6 weeks. Chronic ankle pain can be caused by a variety of osseous or soft-tissue abnormalities, either alone or in combination. For assessing chronic ankle pain, there are multiple imaging options, including radiography, stress radiography, computed tomography (CT) radionuclide bone scanning, ultrasound (US), magnetic resonance imaging (MRI), and various injection procedures. Injection procedures include arthrography, CT arthrography, MR arthrography, and diagnostic injection with anesthetic agents. Although there are numerous causes for chronic ankle pain, common etiologies include osteoarthritis, osteochondral injury, tendon abnormalities, ligament abnormalities and instability, and impingement.


Chronic Ankle Pain

Chronic Ankle Pain. Overview of Imaging Modalities Radiography Radiographs can provide information about the osseous and soft-tissue structures about the ankle. Routine radiographs of the ankle typically include anteroposterior, lateral, and mortise views, the latter obtained by internally rotating the foot 15 to 20 degrees. Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4].


Chronic Ankle Pain

Chronic Ankle Pain. CT CT CT is not routinely used as a first-line imaging tool in chronic ankle pain, but it is more sensitive than radiographs, particularly for osseous abnormalities [5]. CT arthrography may be more accurate than MR arthrography for the identification of osteochondral abnormalities [6].


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan Conventional planar bone scintigraphy can assess osseous pathology. More recently, single-photon emission computed tomography (SPECT) combined with CT has been shown to provide additional information compared with clinical diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft- tissue pathology [7]. In addition, SPECT/CT abnormalities have been shown to significantly correlate with pain in osteochondral lesions [8].


Chronic Ankle Pain

Chronic Ankle Pain. US US can be used to evaluate for soft-tissue abnormalities, including tendon and ligament tears. In inflammatory arthritis, it can help in the assessment of disease activity and severity as well as detect subclinical pathology in early disease or after treatment [9]. US is ideal for dynamic assessment of peroneal tendon instability [10] and can be used to guide interventions [11]. Compared with some other modalities, US is less prone to artifacts, such as susceptibility, motion, magic angle, and streak artifact, but dynamic assessment may be limited in cases of pain.


Chronic Ankle Pain

Chronic Ankle Pain. MRI MRI is the imaging test that globally evaluates all anatomic structures, including ligaments, tendons, cartilage, and bone [12,13]. Most studies have shown that MRI is highly accurate for evaluation of ligament, tendon, and


Chronic Ankle Pain

Chronic Ankle Pain. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.


Chronic Ankle Pain

Chronic Ankle Pain. Reprint requests to: publications@acr.org


Chronic Ankle Pain

Chronic Ankle Pain

Chronic Ankle Pain. Chronic Ankle Pain


Chronic Ankle Pain

Chronic Ankle Pain. osteochondral abnormalities [14-16], although one study found statistically significant lower sensitivity for these abnormalities on MRI as compared to arthroscopy [17]. MRI can identify synovitis and impingement lesions, which can contribute to patient symptoms [18].


Chronic Ankle Pain

Chronic Ankle Pain. Discussion of Procedures by Variant Variant 1: Chronic ankle pain. Initial imaging. Radiography Radiography should be considered as the initial imaging study. Radiographs may reveal osteoarthritis, calcified or ossified intra-articular bodies, osteochondral abnormalities, stress fractures, or evidence of prior trauma. Ankle effusions may also be identified in the anterior ankle joint recess by radiography with 53% to 74% accuracy [19]. They are often associated with ligamentous injury or fracture [19]. The presence of ossific fragments can indicate ligamentous injury or retinaculum avulsion [20], whereas periostitis can occur adjacent to tenosynovitis. Radiographs can also identify synovial osteochondromatosis and erosions from chronic synovitis.


Chronic Ankle Pain

Chronic Ankle Pain. CT CT is not routinely used as the first study for the evaluation of chronic ankle pain.


Chronic Ankle Pain

Chronic Ankle Pain. MRI MRI MRI is not routinely used as the first study for the evaluation of chronic ankle pain.


Chronic Ankle Pain

Chronic Ankle Pain. US US US is not routinely used as the first study for the evaluation of chronic ankle pain.


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan Bone scan is not routinely used as the first study for the evaluation of chronic ankle pain.


Chronic Ankle Pain

Chronic Ankle Pain. Variant 2: Chronic ankle pain. Multiple sites of degenerative joint disease in the hindfoot detected by ankle radiographs. Next study. When multiple sites of osteoarthritis are present, it may be important to determine which joint is the cause of symptoms.


Chronic Ankle Pain

Chronic Ankle Pain. Image-guided Anesthetic Injection Several reports have indicated the effectiveness of fluoroscopic, CT, or US-guided anesthetic [11] with or without corticosteroid injection of joints to identify a source of pain, which aids in surgical planning [21-25].


Chronic Ankle Pain

Chronic Ankle Pain. MRI When degenerative changes of the ankle joint are diagnosed based on radiographs, MRI may be considered as the next best examination to evaluate cartilage integrity, bone marrow, and associated soft tissues, such as ligaments and tendons, if these injuries are clinically suspected [13-15].


Chronic Ankle Pain

Chronic Ankle Pain. CT CT CT without contrast may be helpful to visualize subchondral cysts [5].


Chronic Ankle Pain

Chronic Ankle Pain. US US is not routinely used for the evaluation of degenerative joint disease.


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan Bone scan is not routinely used for the evaluation of degenerative joint disease.


Chronic Ankle Pain

Chronic Ankle Pain. Arthrography Arthrography is not routinely used for the evaluation of degenerative joint disease.


Chronic Ankle Pain

Chronic Ankle Pain. MR Arthrography MR arthrography is not routinely used for the evaluation of degenerative joint disease.


Chronic Ankle Pain

Chronic Ankle Pain. CT Arthrography CT arthrography is not routinely used for the evaluation of degenerative joint disease.


Chronic Ankle Pain

Chronic Ankle Pain. Variant 3: Chronic ankle pain. Ankle radiographs normal, suspected osteochondral lesion. Next study. Osteochondral injuries may involve the talar dome and, less commonly, the tibial plafond and tarsal navicular bone [5,26,27]. If this injury is associated with fracture, osseous cyst, or osteochondral defect, radiography may show the abnormality; however, radiography often fails to show the extent of the osteochondral injury and will be


Chronic Ankle Pain

Chronic Ankle Pain

Chronic Ankle Pain. Chronic Ankle Pain


Chronic Ankle Pain

Chronic Ankle Pain. initially negative if the injury is limited to the articular hyaline cartilage. One multimodality study [5] showed that 41% of osteochondral abnormalities of the ankle were missed on radiography.


Chronic Ankle Pain

Chronic Ankle Pain. MRI In one multimodality study, MRI performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. Although MRI had the highest sensitivity (96%), it was less specific than CT [5]. MRI is effective in determining osteochondral injury instability (sensitivity 97%), most commonly appearing as a high signal line deep to the osteochondral lesion on T2-weighted images or less commonly as a focal defect, an articular fracture, or an adjacent cyst [28]. MRI has also been used to stage these lesions preoperatively with an accuracy of 81% [29] and to assess osteochondral abnormalities after cartilage repair [30]. Although MRI may be less reliable than CT arthrography for talar cartilaginous lesions (accuracy between 76% to 88%) [6], high- resolution MRI using a microscopy coil (eg, a 4-cm receive-only surface coil) can assist in detecting small, clinically relevant features of talar osteochondral lesions that may be missed on standard MRI, including osteochondral junction separation due to focal collapse of the subchondral bone, reparative cartilage hypertrophy, and bone separation in the absence of cartilage fracture [31].


Chronic Ankle Pain

Chronic Ankle Pain. CT Arthrography The introduction of contrast into the ankle joint prior to CT will outline a cartilage surface defect, assisting in lesion detection and assessment for instability. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an accuracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6].


Chronic Ankle Pain

Chronic Ankle Pain. MR Arthrography The introduction of contrast into the ankle joint prior to MRI will outline a cartilage surface defect, assisting in lesion detection and assessment for instability. One study comparing CT arthrography and MR arthrography for talar cartilaginous lesions found an accuracy between 76% to 88% using MR arthrography compared to 90% to 92% for CT arthrography, suggesting that CT arthrography may be more reliable [6].


Chronic Ankle Pain

Chronic Ankle Pain. CT In one multimodality study, CT (noncontrast, multidetector with multiplanar reformatted images) performed similarly to arthroscopy for the evaluation of osteochondral abnormalities of the ankle [5]. However, CT was more specific (99%) but less sensitive then MRI [5].


Chronic Ankle Pain

Chronic Ankle Pain. US US is not routinely used for the evaluation of osteochondral lesions in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. Radiography Stress views are not routinely used for the evaluation of osteochondral lesions in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. Arthrography Arthrography is not routinely used for the evaluation of osteochondral lesions in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. Variant 4: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected tendon abnormality. Next study. Possible tendon abnormalities include tenosynovitis, tendinopathy, tendon tear (partial or complete), and tendon subluxation or dislocation. Both MRI and US can effectively demonstrate ankle tendon abnormalities, although US results are more dependent on operator skill and expertise [10,35]. For the assessment, it is assumed the procedure is performed and interpreted by an expert.


Chronic Ankle Pain

Chronic Ankle Pain. US US can be used to evaluate for soft-tissue abnormalities, including tendon and ligament tears. It has been shown to produce similar results as MRI in diagnosing ankle tendon tears, although US results are more dependent on operator skill and expertise [10,35]. In this case, it is assumed that the procedure is performed and interpreted by an expert. One study showed that it had a sensitivity of 100% and an accuracy of 93% compared to surgical findings [36]. With regard to the tibialis posterior tendon, one study evaluating tendon pathology showed that US was slightly less sensitive than MRI; however, this difference did not significantly affect clinical management [37]. One study using US showed 100% sensitivity and 90% accuracy in diagnosing peroneal tendon tears [38]; suggesting that US may be more useful than MRI. With regard to chronic Achilles tendinopathy, US detected 21 of 26 cases of tendinosis and partial rupture [39], and another study showed that US can differentiate full- thickness from partial-thickness Achilles tears with 92% accuracy [40]. In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, it can be used to guide interventions such as concurrent performance of US-guided intrasheath anesthetic injections [11]. It can also be used for direct intratendinous biologic injection and dry needling [41-43].


Chronic Ankle Pain

Chronic Ankle Pain. One significant advantage of US is in the dynamic assessment for tendon subluxation (including intrasheath subluxation) and dislocation, with a reported positive predictive value of 100% compared to surgical findings [44,45].


Chronic Ankle Pain

Chronic Ankle Pain. US-guided sheath injections are more accurate than palpation guided and allow for precise positioning of the needle tip in the sheath rather than the tendon substance because a large volume intratendinous injection of corticosteroids or local anesthetic can result in a split tear [46].


Chronic Ankle Pain

Chronic Ankle Pain. US can detect intratendinous tophi in gout, enthesitis of the Achilles tendon or plantar fascia in spondyloarthritis, and tenosynovitis in spondyloarthritis and rheumatoid arthritis [47].


Chronic Ankle Pain

Chronic Ankle Pain. MRI It is generally accepted that MRI can achieve high sensitivities (>90%) in diagnosing ankle tendon tears [16]. Regarding tibialis posterior tendon, MRI is more sensitive than US; however, this difference did not significantly affect clinical management [37]. With regard to peroneal tendinopathy and tendon tear, one study found the sensitivities and specificities of MRI to be 83.9% and 74.5%, respectively, for tendinopathy and 54.5% and 88.7%, respectively, for tendon tears [48]. With regard to chronic Achilles tendinopathy, MRI detected 26 of 27 cases of tendinosis and partial rupture [39]. MRI reported a 66% accuracy rate for assessment for tendon subluxation and dislocation [44,45]. MRI evidence of peroneal tendon pathology should be treated with caution because up to 34% of asymptomatic patients may have a tear of the peroneus brevis tendon [49]. One study showed that MRI evidence of peroneal tendon pathology had a 48% positive predictive value for clinical findings, highlighting the importance of clinical examination [50].


Chronic Ankle Pain

Chronic Ankle Pain. Image-guided Anesthetic Injection In addition to the diagnostic capabilities of US, when a tendon abnormality is detected, a fluoroscopic or US- guided intrasheath anesthetic injection can be concurrently performed [11].


Chronic Ankle Pain

Chronic Ankle Pain. Tenography Diagnostic and therapeutic ankle tenography can also be considered for evaluation, with one study reporting that 47% of patients had prolonged relief of symptoms [51].


Chronic Ankle Pain

Chronic Ankle Pain. CT CT is not routinely used for the evaluation of suspected tendon abnormality.


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan Bone scan is not routinely used for the evaluation of suspected tendon abnormality.


Chronic Ankle Pain

Chronic Ankle Pain. CT Arthrography CT arthrography is not routinely used for the evaluation of suspected tendon abnormality.


Chronic Ankle Pain

Chronic Ankle Pain. MR Arthrography MR arthrography is not routinely used for the evaluation of suspected tendon abnormality.


Chronic Ankle Pain

Chronic Ankle Pain. Arthrography Arthrography is not routinely used for the evaluation of suspected tendon abnormality.


Chronic Ankle Pain

Chronic Ankle Pain

Chronic Ankle Pain. Chronic Ankle Pain


Chronic Ankle Pain

Chronic Ankle Pain. Radiography Stress views are not routinely used for the evaluation of suspected tendon abnormality.


Chronic Ankle Pain

Chronic Ankle Pain. Variant 5: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle instability. Next study. In the absence of findings on routine radiography, imaging options to evaluate ligamentous integrity include stress radiography, MRI, MR arthrography, CT arthrography, and US.


Chronic Ankle Pain

Chronic Ankle Pain. MRI One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 97% for MRI when compared to arthroscopic findings. Additionally, MRI identified the exact location of the injury in 93% of the cases [15]. Comparing MRI with arthroscopy, studies have shown a range of accuracies of chronic lateral ligament tearing (either partial or complete), ranging from 77% to 92% for the anterior talofibular ligament and 88% to 92% for the calcaneofibular ligament [14,52]. For the evaluation of deep deltoid ligament tears, MRI is both sensitive and specific compared with arthroscopy, with reported values of 96% and 98%, respectively [53].


Chronic Ankle Pain

Chronic Ankle Pain. With regard to tears of the tibiofibular ligaments of the tibiofibular syndesmosis, MRI has a reported accuracy of 100% [54]. Additionally, MRI can also demonstrate interosseous membrane tears [55]. MRI offers the advantage of evaluating for injuries associated with or mimicking lateral instability that may not be diagnosed on stress radiography such as tenosynovitis, tendon injury, and osteochondral lesions [56]. MRI may also be used to evaluate the ankle after lateral ligament reconstruction [57].


Chronic Ankle Pain

Chronic Ankle Pain. MR Arthrography MR arthrography can be helpful for the assessment of chronic ankle instability due to lateral collateral ligament injuries [12].


Chronic Ankle Pain

Chronic Ankle Pain. US One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 91% for US when compared to arthroscopic findings. Additionally, US identified the exact location of the injury in 63% of cases [15]. Another study comparing US and CT arthrography for the diagnosis of anterior talofibular ligament injury showed an accuracy of 61% using US and 71% for CT arthrography [58]. US also has the dynamic capability of stressing the ligament and looking for laxity or frank separation of the injured ligament [1,59].


Chronic Ankle Pain

Chronic Ankle Pain. With regard to interosseous membrane tears, US has a proven sensitivity of 89% and specificity of 94.5% in diagnosing interosseous membrane tears shown at surgery [55,60].


Chronic Ankle Pain

Chronic Ankle Pain. Radiography Stress radiographs can be used to assess ankle instability [1,2]; however, some have questioned their accuracy [3,4]. One study evaluating anterior talofibular ligament injury demonstrated a diagnostic accuracy of 67% for stress radiography [15]. Oae et al [15] compared stress radiography to arthroscopic findings and found the former has an accuracy of 67% for evaluating anterior talofibular ligament injuries. Subtalar stress radiography using forced dorsiflexion and supination [4] or talar rotation [61] can be used to evaluate subtalar laxity.


Chronic Ankle Pain

Chronic Ankle Pain. CT Arthrography CT arthrography showed an accuracy of 71% for diagnosing anterior talofibular ligament injury [58].


Chronic Ankle Pain

Chronic Ankle Pain. CT CT CT is not routinely used for the evaluation of ligamentous integrity.


Chronic Ankle Pain

Chronic Ankle Pain. Arthrography Arthrography is not routinely used for the evaluation of ligamentous integrity.


Chronic Ankle Pain

Chronic Ankle Pain. Image-guided Anesthetic Injection Image-guided anesthetic injection is not routinely used for the evaluation of ligamentous integrity.


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan Bone scan is not routinely used for the evaluation of ligamentous integrity.


Chronic Ankle Pain

Chronic Ankle Pain. Variant 6: Chronic ankle pain. Ankle radiographs normal or nonspecific, suspected ankle impingement syndrome. Next study. Imaging can also be used to diagnose ankle impingement syndromes, which can occur in the anterolateral, anterior, anteromedial, posteromedial, and posterior aspects of the ankle joint [62-71].


Chronic Ankle Pain

Chronic Ankle Pain. MR Arthrography MR arthrography has been found to be an accurate method for assessing both anterolateral and anteromedial impingement with the advantage of joint capsule distention by intra-articular contrast injection [68,69].


Chronic Ankle Pain

Chronic Ankle Pain. US One study involving anterolateral ankle impingement compared US to arthroscopic findings. The study found US had a sensitivity and specificity of 77% and 57%, respectively [70]. US also showed abnormal soft tissues in anterolateral impingement, with a reported accuracy of 100% in one study [72].


Chronic Ankle Pain

Chronic Ankle Pain. MRI Studies on the accuracy of MRI in diagnosing anterolateral impingement syndrome have drawn varying conclusions, which may be related to varying MRI magnet strengths and inconsistent protocols [73]. Comparing MRI with surgical findings, studies have shown sensitivities between 75% to 83% and specificity between 75% to 100% for the diagnosis of anterolateral impingement [73,74].


Chronic Ankle Pain

Chronic Ankle Pain. One study found that, when compared with arthroscopy, fat-suppressed, IV contrast-enhanced, 3-D gradient- recalled echo imaging was sensitive for the evaluation of synovitis of the ankle associated with trauma (92%), whereas it was specific for soft-tissue impingement evaluation (97%) when the ankle was divided into four compartments: the anterolateral gutter, anteromedial gutter, anterior recess, and posterior recess [75].


Chronic Ankle Pain

Chronic Ankle Pain. MRI is useful in confirming the diagnosis, evaluating patients with an uncertain clinical diagnosis, and planning surgery. Additionally, it can help exclude other pathologic entities that may mimic or coexist with impingement syndromes. However, MRI features supportive of impingement may be present in asymptomatic individuals, and an accurate diagnosis requires careful correlation of imaging features findings with clinical findings [76]. There are only limited reports on the use of MRI for the other forms of ankle impingement syndrome, so its accuracy in these conditions is not well established [62,64,67,68].


Chronic Ankle Pain

Chronic Ankle Pain. CT Arthrography One study involving anterolateral ankle impingement compared CT arthrography to arthroscopic findings. The study found that CT arthrography had a sensitivity and specificity of 97% and 71%, respectively [77].


Chronic Ankle Pain

Chronic Ankle Pain. Image-guided Anesthetic Injection Fluoroscopic or US-guided injections have been shown as an effective treatment for some ankle impingement syndromes [78,79].


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan with SPECT or SPECT/CT Recently, SPECT combined with CT has been shown to provide additional information compared with clinical diagnosis and conventional bone scintigraphy for the evaluation of impingement syndromes and soft-tissue pathology [7]. One study found that SPECT/CT provided information not suspected on clinical diagnosis in 56% of cases with impingement syndromes or soft-tissue pathology [7].


Chronic Ankle Pain

Chronic Ankle Pain. CT CT CT may be useful for depiction of osseous causes of impingement, such as chronic abnormalities between the talus and an os trigonum or fractures of the lateral tubercle of the talus or os trigonum [62].


Chronic Ankle Pain

Chronic Ankle Pain. Arthrography Arthrography is not routinely used for the evaluation of ankle impingement syndromes.


Chronic Ankle Pain

Chronic Ankle Pain. Radiography Stress views are not routinely used for the evaluation of ankle impingement syndromes.


Chronic Ankle Pain

Chronic Ankle Pain. Variant 7: Chronic ankle pain. Ankle radiographs normal, pain of uncertain etiology. Next study. When chronic ankle pain is of unclear etiology, normal ankle radiographs can be followed by other imaging tests, primarily directed by clinical findings.


Chronic Ankle Pain

Chronic Ankle Pain

Chronic Ankle Pain. Chronic Ankle Pain


Chronic Ankle Pain

Chronic Ankle Pain. MRI If the patient has a focal soft-tissue abnormality, MRI can be considered. Peripheral nerve-related symptoms can be evaluated with US or MRI; however, US has the benefit of higher resolution. If symptoms are believed to originate from osseous structures, MRI can be considered if there is concern for an initially missed fracture [80]. MRI is effective in detecting osseous stress injuries [81]. Overall, MRI is the imaging test that globally evaluates all anatomic structures, including bone marrow [13,82].


Chronic Ankle Pain

Chronic Ankle Pain. US US is best used as a focal examination and should not be used for comprehensive evaluation of the ankle when no particular pathology is suspected. If the patient has a focal soft-tissue abnormality, US can be considered. Peripheral nerve-related symptoms can be evaluated with US or MRI; however, US has the benefit of higher resolution. US with dynamic evaluation should be considered when symptoms are only present during specific movements or positions [83,84].


Chronic Ankle Pain

Chronic Ankle Pain. CT If symptoms are believed to originate from osseous structures, CT can be considered if there is concern for an initially missed fracture [80]. CT has been shown to be superior to radiography for fracture detection [85].


Chronic Ankle Pain

Chronic Ankle Pain. Bone Scan with SPECT or SPECT/CT SPECT/CT is an emerging imaging modality for evaluation of ankle pathology and can detect osteochondral lesions, osteoarthritis, tarsal coalition, occult fractures, or painful accessory bones [86].


Chronic Ankle Pain

Chronic Ankle Pain. Arthrography Arthrography is not routinely used for the evaluation of pain of unknown etiology in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. CT Arthrography CT arthrography is not routinely used for the evaluation of pain of unknown etiology in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. MR Arthrography MR arthrography is not routinely used for the evaluation of pain of unknown etiology in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. Image-guided Anesthetic Injection US-guided nerve blocks have been reported to be helpful for diagnostic purposes and to plan for surgical or procedural intervention [87-89].


Chronic Ankle Pain

Chronic Ankle Pain. Radiography Stress views are not routinely used for the evaluation of pain of unknown etiology in the ankle.


Chronic Ankle Pain

Chronic Ankle Pain. Although there are references that report on studies with design limitations, 15 well-designed or good-quality studies provide good evidence.


Chronic Ankle Pain

Chronic Ankle Pain. Supporting Documents For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. The literature regarding etiology of acute, rather than chronic, pain in postmenopausal women is somewhat limited. In a single-center study, investigators noted that ovarian cysts account for one-third of the cases of pain attributed to gynecologic origin in perimenopausal and postmenopausal women [3]. This is a slightly less common cause of pain than in the reproductive age group. Uterine fibroids are the are the second most common cause of acute pelvic pain in the peri/postmenopausal group, and a significantly more common cause of pain than in the premenopausal group [3]. Acute pain from fibroids may be secondary to torsion of pedunculated fibroids, prolapse of a submucosal fibroid, or from acute infarction/hemorrhage in a degenerating fibroid. The third most common cause of pelvic pain is pelvic infection, which accounts for 20% of cases [3]. These cases of pelvic inflammatory disease (PID) include tubo-ovarian abscess, oophoritis, salpingitis, endometritis, cervicitis, or peritonitis from gynecologic origin. The majority of these are related to sexual activity; however, recent instrumentation and surgery are common iatrogenic causes. Isolated endometritis can also be seen with cervical stenosis. The fourth most common gynecologic cause of acute pelvic pain is ovarian neoplasm, which is the etiology in 8% of cases [3]. Ovarian torsion, retained intrauterine device, and endometriosis have been reported as causes of acute pain in the postmenopausal period; however, these are considered rare.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. In the postmenopausal woman, other causes of pelvic pain are attributable to the urinary, gastrointestinal, and vascular systems [4]. Imaging recommendations vary for these etiologies, and narrowing of the differential will help ensure optimal diagnostic imaging. Please see the corresponding ACR Appropriateness Criteria guidance document, which addresses these diagnoses listed in Appendix 1.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. OR Reprint requests to: publications@acr.org


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Postmenopausal Acute Pelvic Pain


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Discussion of Procedures by Variant Variant 1: Postmenopausal acute pelvic pain. Initial imaging. CT Abdomen and Pelvis CT abdomen and pelvis may be useful in the setting of poorly localized pain, masses, or organomegaly involving both the abdomen and pelvis as well as in assessment of abdominal vasculature and ascites.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. CT is useful in the evaluation of patients with a nonspecific clinical presentation or broad differential diagnosis, including gynecologic and nongynecologic etiologies, and may be a first-line imaging modality in this setting. CT with intravenous (IV) contrast had higher sensitivity than ultrasound (US) (89% versus 70%) for urgent diagnoses in a mixed-gender group of adults with abdominopelvic pain [5], and approximately 88% overall accuracy compared with surgical diagnosis in a similar cohort [6]. Although specific data are lacking for the postmenopausal population, CT is also widely used as a second-line imaging modality in patients with an equivocal or nondiagnostic US evaluation, particularly when there is concern for appendicitis [7,8]. The bulk of evidence to support the use of a CT abdomen and pelvis in acute postmenopausal pelvic pain refers to contrast-enhanced imaging.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. For gynecologic diagnoses, contrast-enhanced CT may identify ovarian cysts and masses, including solid components, as well as ascites, or lymphadenopathy that may raise suspicion for a malignant diagnosis [9-11]. However, the accuracy of CT for adnexal mass characterization remains limited. CT is distinctly helpful when macroscopic fat or calcifications of teeth or bone fragments are present, to confirm the diagnosis of ovarian teratoma. Regarding ovarian torsion, CT findings have been described but specific diagnostic accuracy has not been reported to our knowledge. CT findings of ovarian torsion include an enlarged, featureless, and hypoenhancing ovary, sometimes with apparent swirling of vascular pedicle and abnormal craniocaudal orientation of ovary or uterine deviation to the affected side [12-16].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Contrast-enhanced CT may be helpful for identification of uterine fibroids that have undergone torsion or necrosis [12,17], with the findings of diminished contrast enhancement of the fibroid(s) (86% sensitivity) and ascites (100% sensitivity) demonstrating the best diagnostic performance in a series of 51 cases [18]. CT is also helpful in evaluation of fibroids when calcified masses cause shadowing and limit visualization of the pelvic contents by US [19].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Contrast-enhanced CT may aid in the early diagnosis of PID with the findings of pelvic fluid, loss of normal fat planes, and/or subtle enhancement of the endocervical canal or fallopian tubes prior to emergence of the dilatation and enlargement that can be identified with US [20,21]. Fulminant PID on CT demonstrates fluid in the endometrial canal, distended and thickened fallopian tubes with wall enhancement, and ovarian enlargement [12,20,22]. CT findings late in the course of PID with formation of a tubo-ovarian abscess includes a complex cystic mass with thick enhancing walls [14,22] and anterior displacement of the mesosalpinx, which helps to distinguish tubo-ovarian abscess from other sources of abscess formation in the pelvis [12,22,23].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. MRI Pelvis MRI is most often utilized as a problem-solving examination if US or CT do not reveal an etiology of pain. Potential benefits of MRI in the acute pelvic pain setting are high spatial resolution and excellent soft-tissue contrast. This allows for more precise localization and origin of pathology identified on US and CT [12,24].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Contrast-enhanced MRI provides the greatest soft-tissue detail for evaluation of uterine fibroids and is particularly helpful in evaluating for symptomatic complications including hemorrhage, torsion, infarction, and prolapse [22,31- 33]. MRI is probably not necessary as a primary imaging modality in uncomplicated cases of PID, but it is useful for anatomic specificity and facilitating treatment planning [12,24,34,35]. MRI is reported to be 95% sensitive and 89% specific for evaluation of hydrosalpinx [36].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. The majority of the above reports have focused on the utility of contrast-enhanced MRI, but valuable information can often be derived from noncontrast protocols with emphasis on T2-weighted imaging. Abbreviated MRI


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Postmenopausal Acute Pelvic Pain protocols without IV contrast have demonstrated 73% accuracy for diagnosis of acute pelvic pain in a mixed group of men, pregnant women, and nonpregnant women [29].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. US Pelvis Transabdominal US is considered a first-line imaging modality for evaluation of pelvic pain of suspected gynecologic origin [37]. Transabdominal US is most often performed in conjunction with transvaginal US. Transabdominal US has the benefit of a larger field of view that allows visualization of the uterus and adnexa, but also the remainder of the pelvic contents, including free pelvic fluid. Transabdominal US is well tolerated by patients; however, it can be limited by patient body habitus. The evidence presented below for transvaginal US generally assumes a combined approach using both techniques.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. US Pelvis Transvaginal Transvaginal US is considered a first-line imaging modality for evaluation of pelvic pain of suspected gynecologic origin and, although it may be performed independently, is usually performed at the same time as a transabdominal US per the ACR-ACOG-AIUM-SPR-SRU Practice Parameter for the Performance of Ultrasound of the Female Pelvis [37]. Color Doppler is considered a standard component of a pelvic US examination and is usually performed simultaneously, with the addition of spectral Doppler when indicated, particularly in the setting of concern for torsion. The benefits of transvaginal US include the close proximity of the high-frequency probe to the reproductive system with less intervening bowel gas and adipose tissue that can attenuate the US beam and decrease imaging quality. There is little primary prospective evidence to critically evaluate the role of US for the broad presentation of pelvic pain, but it is standard clinical practice [1,4,8,38,39]. Of note, 26.8% of postmenopausal women reported pain while undergoing a transvaginal US, a potential limitation in this patient group [40].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. US is the most common initial imaging study for evaluation of uterine fibroids, though there is little primary prospective evidence to support its use [50,51]. US readily demonstrates the size and location of most fibroids but is probably less sensitive than MRI for assessing complications such as necrosis or hemorrhagic degeneration, extrapolating from the literature on postprocedural assessment after uterine fibroid embolization [32,33,52].


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Postmenopausal Acute Pelvic Pain

Postmenopausal Acute Pelvic Pain


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Introduction/Background Orbital disorders in children consist of varied pathologies affecting orbits, orbital contents, visual pathway, and innervation of the extraocular or intraocular muscles. Clinical manifestations of these disorders may range from ophthalmoplegia, decreased visual acuity, diplopia, nystagmus, exophthalmos/enophthalmos, papilledema, orbital soft tissue swelling, orbital pain, and, in most severe cases, monocular or binocular vision loss. The underlying etiology of these disorders may be traumatic or nontraumatic.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Detailed clinical history along with a thorough clinical examination, including ophthalmologic and neurologic examination, is frequently able to localize the abnormality along the visual pathway. Presumed location of the lesion along with the additional findings like eye pain, swelling, exophthalmos/enophthalmos, erythema, conjunctival vascular dilatation, intraocular pressure, and so on, help in determining if imaging is needed, modality of choice, and extent of coverage (orbits and /or head) [1]. Occasionally clinical signs and symptoms may be nonspecific, and, in these cases, diagnostic imaging studies play key role in depicting the nature and extent of the injury or disease [2].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Localization of the orbital abnormality on imaging is facilitated by a compartmental approach, which helps in the differential diagnosis based on the lesion location within the orbit (globe, extraconal, or intraconal space) or elsewhere in the visual pathway [3].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Traumatic injury in the setting of head injury or nonaccidental injury is discussed separately in ACR Appropriateness Criteria on these topics and is therefore excluded from this review.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Special Imaging Considerations Ultrasound (US) is also an important diagnostic tool but is most often performed by the ophthalmologist or emergency physician and therefore not covered in this article.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Reprint requests to: publications@acr.org


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child Discussion of Procedures by Variant Variant 1: Child. Traumatic visual loss. Suspected orbital injury. Initial imaging. Traumatic injury is the leading cause of noncongenital monocular vision loss in children [4]. Common signs of orbital injuries include periorbital soft tissue swelling, ecchymosis, hyphemia, subconjunctival hemorrhage, diplopia, restriction of ocular movement, or vision loss. The most common causes of pediatric orbital fractures are motor vehicle collision, sports injury, falls, and assault [5]. Data from combined pediatric and adult series show that ocular injuries account for approximately 3% of all visits to the emergency department [6]. Orbital fractures account for 3% to 45% of all pediatric facial fractures [5]. Orbital roof fractures are the most common orbital fractures in children <8 years of age, and orbital floor fractures are most common in older children [7]. Serious ocular injuries in conjunction with orbital fracture are less common in children compared with adults. In one series, serious ocular injury was reported in approximately 20% of children with orbital fractures [7].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Traumatic brain injuries are more commonly associated with orbital fractures in younger children because orbital roof fractures are more common in this age group [7]. Elastic, cancellous bone with resilient periosteum in children leads to trap door orbital fracture, which in turn causes entrapment of the extraocular muscles or other orbital contents [8], leading to restriction of ocular movement and diplopia. Incarceration of the inferior rectus muscle within a trap door fracture may rapidly result in ischemic injury of the muscle and subsequent restrictive strabismus. However, diplopia itself does not imply extraocular muscle entrapment as soft tissue swelling, hematoma, or nerve paresis can also lead to restricted ocular movement [9]. The presence of visual loss or visual field defects suggests direct or indirect injury to the globe or optic nerve.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Open globe injury may be a result of blunt trauma (globe rupture) or penetrating injury (globe laceration). Penetrating injuries may also be associated with intraorbital foreign body. Imaging may be conducted to assess for the intraorbital foreign body, extent of globe damage, and injury to the surrounding structures [10,11].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head CT of the head may have a complementary role when obtained along with CT orbits in cases in which intracranial abnormality or calvarial fracture is suspected, particularly in children with suspected orbital roof fracture. Outside the setting of concurrent head trauma, there is no relevant literature to support the role for CT head in the initial evaluation of the orbital trauma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits CT is considered the most useful imaging modality in evaluating orbital trauma, and it is the most accurate method in detecting fractures [12]. CT may also provide information for the detection of soft tissue injuries (including globe or extraocular muscles), hemorrhage, and presence of an intraocular foreign body. CT was found to be 94.9% sensitive for detection of the intraorbital foreign body, especially metallic or glass foreign bodies [13]. There is no relevant literature to support the role for contrast-enhanced CT orbits in the initial evaluation of the orbital trauma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CT angiography (CTA) head in the initial evaluation of orbital trauma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MR angiography (MRA) head in the initial evaluation of orbital trauma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head MRI of the head provides more detailed information about brain parenchyma and other intracranial structures due to its superior soft tissue contrast (versus CT) but remains supplementary to a CT as an initial imaging modality in the setting of orbital trauma. There is no relevant literature to support the role of contrast-enhanced MRI head in the initial evaluation of the orbital trauma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits MRI of the orbits may provide useful detailed information due to its superior soft tissue contrast, particularly in the evaluation of the globe and optic nerves. MRI may also be useful in detecting nonmetallic intraorbital foreign body, especially a wooden foreign body, which may appear hypoattenuating on CT and may be mistaken for air [12]. However, it remains supplementary to a CT scan as an initial imaging modality in orbital trauma. There is no relevant literature to support the role of contrast-enhanced MRI orbits in the initial evaluation of orbital trauma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child Radiography Orbit Radiography is insufficient in the detection of the pathology in cases of orbital trauma and has been replaced by CT in current clinical practice [12]. Radiography of the orbits may have a role as a screening modality for the detection of a metallic intraorbital foreign body before performing an MRI scan. However, a CT scan of the orbits is a more sensitive modality for detection of metallic intraocular foreign body and is usually performed prior to MRI in cases of orbital trauma [12,13].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Variant 2: Child. Nontraumatic acute vision loss without papilledema. Initial imaging. Causes of acute nontraumatic vision loss in children may be due to ocular abnormalities or lesions in the neurovisual pathway. Ocular abnormalities involving the cornea, lens, or anterior chamber are best diagnosed by an ophthalmologic examination. Various abnormalities of the neurovisual pathway (including optic nerve, optic chiasm, optic tracts, thalamus, optic radiations, or visual cortex) that may present with acute visual loss or defect are covered in this variant. These may include optic neuritis, which may be secondary to demyelinating disorders (multiple sclerosis, neuromyelitis optica spectrum disorders), other inflammatory, infectious, or granulomatous disorders, or unknown underlying cause (idiopathic). This variant also includes lesions involving the brain parenchyma in the region of thalamus, optic radiations, or occipital lobes, which may have acute presentation (eg, infarct, hemorrhage, inflammatory, infectious, or demyelination processes). Ocular migraine is a common cause of transient acute monocular vision loss with ipsilateral headache in adolescents. It is diagnosed based on the clinical history and examination. Imaging is performed to exclude other causes of vision loss and headache [14].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Lastly, nonorganic (psychogenic) acute vision loss is not uncommon in school age children. These are diagnosed by exclusion, based on the clinical history, inconsistent clinical examination, and negative imaging studies [15,16].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children with nontraumatic vision loss.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head CT of the head without intravenous (IV) contrast may be complementary to MRI head for a suspected brain lesion, especially if infarct or hemorrhage in the neurovisual pathway is suspected. There is no relevant literature to support the role for contrast-enhanced CT head in the initial evaluation of children with nontraumatic vision loss.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits There is no relevant literature to support the use of CT orbits in the initial evaluation of children with nontraumatic vision loss.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of children with nontraumatic vision loss.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children with nontraumatic vision loss.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children with nontraumatic vision loss.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head MRI of the brain without IV contrast may also be complementary to CT scan for confirmation of acute infarct or intracranial hemorrhage. MRI head with and without IV contrast is obtained to evaluate the brain for intracranial demyelinating lesions, location, and distribution, which helps determine appropriate differential diagnosis [17,18].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head and Orbits MRI of the head and orbits with and without IV contrast is the most useful imaging modality for the evaluation of acute nontraumatic vision loss. T1-weighted postcontrast images with fat suppression were reported to identify abnormal enhancement of the optic nerve in 95% of cases of optic neuritis [19]. MRI is also the most useful modality for the evaluation of the lesions involving extraorbital neurovisual pathway and the remainder of the brain parenchyma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child MRI Orbits MRI of the orbits with and without IV contrast is useful for evaluation of globes and optic nerves in cases of acute nontraumatic vision loss. T1-weighted postcontrast images with fat suppression were reported to identify abnormal enhancement of the optic nerve in 95% of cases of optic neuritis [19]. In the setting of acute vision loss, MRI of the orbits alone is inadequate, and it is usually performed along with an MRI of the head because the pathologies leading to visual loss frequently involve extraorbital neurovisual pathway and other locations within the brain parenchyma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Variant 3: Child with isolated nystagmus. Initial imaging. Pediatric nystagmus can be classified as infantile (onset in first 6 months of life) or acquired (later onset) [23]. The most common causes of infantile nystagmus are albinism, retinal disease, low vision, or vision deprivation (congenital cataract) and other retinal disorders [23,24]. These are typically diagnosed with a clinical ophthalmological examination and genetic workup. Infantile nystagmus may also occur in fusion maldevelopment syndrome, which occurs in children with normal ocular development and retinal function.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Acquired nystagmus may be caused by anterior optic pathway lesions (tumors), lesions of the brainstem/cerebellum (structural lesions or space occupying lesions), or various metabolic diseases (leukodystrophies, mitochondrial diseases, etc) [23,25]. Neuroimaging is frequently needed in these cases to exclude above structural lesions, especially in patients with late onset nystagmus, in the presence of concurrent neurological symptoms, with decreased visual acuity, or in the presence of asymmetric/unilateral or progressive nystagmus [26-28].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Batmanabane et al [29] retrospectively reviewed charts of 148 children who underwent MRI for isolated nystagmus; 23 (15.5%) of these children had abnormal intracranial findings. Most common abnormalities on MRI included abnormal T2 hyperintense signal in white matter (4%), Chiari 1 malformation (3.4%), and optic pathway glioma (2%). This study did not find an association between the time of the onset of nystagmus and abnormal MRI. This study also suggested that administration of IV contrast is not required in all cases with isolated nystagmus and can be considered in children with a suspicious lesion on MRI. Similarly, only 2% of subjects in this study had intraorbital abnormalities that benefitted from dedicated orbital sequences. MRI of the orbits may be considered if the initial screening MRI brain is suspicious for orbital abnormalities [29].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Vestibular nystagmus is also a common form of acquired nystagmus. It may result from the dysfunction of the peripheral (labyrinth, vestibular nerve) or central vestibular pathways (root entry zone of the VIII cranial nerve, brain stem vestibular nuclei to ocular nuclei). The role of imaging is to primarily exclude VIII cranial nerve or brainstem lesion [30].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Spasmus nutans is a rare form of nystagmus that is characterized by a triad of nystagmus, head bobbing, and torticollis. It usually appears at 1 to 3 years of age and abates by 5 to 12 years of age. It usually cannot be easily differentiated from the nystagmus associated with retinal disorders or other lesions caused by anterior visual pathway tumors. Therefore, thorough neuro-ophthalmological and neuroradiological workup with MRI is necessary in these cases [23].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children with isolated nystagmus.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head There is no relevant literature to support the use of CT head in the initial evaluation of children with isolated nystagmus.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child CT Orbits There is no relevant literature to support the use of CT orbits in the initial evaluation of children with isolated nystagmus.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children with isolated nystagmus.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children with isolated nystagmus.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head and Orbits MRI head and orbits without or with IV contrast may be helpful as initial imaging in children with isolated nystagmus [27]. Batmanabane et al [29] retrospectively reviewed charts of 148 children who underwent MRI for isolated nystagmus; 23 (15.5%) of these children had abnormal intracranial findings. Most common abnormalities on MRI included abnormal T2 hyperintense signal in white matter (4%), Chiari 1 malformation (3.4%), and optic pathway glioma (2%).


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head MRI of the head without and with IV contrast may be helpful to evaluate for intracranial abnormalities in children presenting with isolated nystagmus [29]. Batmanabane et al [29] retrospectively reviewed charts of 148 children who underwent MRI for isolated nystagmus; 23 (15.5%) of these children had abnormal intracranial findings. Most common abnormalities on MRI included abnormal T2 hyperintense signal in white matter (4%), Chiari 1 malformation (3.4%), and optic pathway glioma (2%).


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits There is no relevant literature to support MRI orbits without or with IV contrast as initial imaging in children with isolated nystagmus. However, it may be considered an adjunct to the MRI of the brain if obtained concurrently. Batmanabane et al [29] retrospectively reviewed charts of 148 children who underwent MRI for isolated nystagmus; 23 (15.5%) of these children had abnormal intracranial findings. Most common abnormalities on MRI included abnormal T2 hyperintense signal in white matter (4%), Chiari 1 malformation (3.4%), and optic pathway glioma (2%).


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Variant 4: Child. Congenital or developmental abnormality leading to decreased visual acuity or vision loss. No leukocoria. Unilateral or bilateral. Initial imaging. Various developmental abnormalities that typically present with decreased acuity or loss of vision primarily include abnormalities of the globes and optic nerves. Abnormalities of the globe may include anophthalmus, microphthalmos, macropthalmos, anterior segment dysgenesis, or coloboma [2]. These disorders are best evaluated with clinical examination, ophthalmoscopy, and measurement of the size of the globe with ocular US. However, imaging may be helpful in complex abnormalities, which are difficult to delineate by US or for evaluation of the associated syndromes and developmental abnormalities in the brain (eg, coloboma on the setting of Aicardi syndrome) [2].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Children with bilateral ONH usually present in infancy with poor vision and nystagmus, whereas unilateral or asymmetric ONH may be detected later due to strabismus. Indirect ophthalmoscopy is usually sufficient to diagnose severe ONH, but in mild to moderate cases, diagnosis is more challenging. Although imaging is usually obtained for known or suspected ONH to evaluate a child for associated central nervous system abnormalities, studies have also investigated the usefulness of MRI as a diagnostic modality for ONH [34].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head There is no relevant literature to support the use of CT head in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits There is no relevant literature to support the use of CT orbits in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head and Orbits MRI of the head and orbits without IV contrast is the most useful modality for evaluation of the developmental abnormalities of the globes, optic nerves, and associated abnormalities in the brain and pituitary gland [2,32-34]. The sensitivity and specificity of MRI for the detection of pituitary abnormality in the patients with ONH and endocrinopathy are 68% to 96% and 83% to 92%, respectively [32,33]. MRI may also complement fundoscopic examination in the primary diagnosis of ONH by direct measurement of the optic nerve size [34]. There is no relevant literature to support the role for IV contrast in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head There is no relevant literature to support the use of MRI head alone in the initial evaluation of children without leukocoria with decreased visual acuity or vision loss due to congenital or developmental abnormality. MRI of the head is, however, often obtained in conjunction with MRI orbits.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits MRI of the orbits alone is useful to evaluate for the abnormalities of the globe and orbits, but this is best performed in association with MRI of the brain, to assess the associated developmental abnormalities of the intracranial structures [2,32-34].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children with suspected OPG.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head There is no relevant literature to support the use of CT head in the initial evaluation of children with suspected OPG.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss-Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits There is no relevant literature to support the use of CT head in the initial evaluation of children with suspected OPG.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children with suspected OPG.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children with suspected OPG.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head and Orbits MRI of the head and orbit with and without IV contrast is the most useful imaging modality in diagnosis and evaluation of the extent of the symptomatic OPG in patients with or without NF-1 [36,37]. The role of MRI in the early detection of OPG in asymptomatic children with NF-1 is controversial, because there is no evidence it could improve the clinical outcome of patients in reducing the incidence of visual loss [38,39]. The role of IV contrast in the surveillance and follow-up of the optic pathway glioma is not entirely clear, because tumor volume variation is sufficient in most cases to assess tumor progression [38,39].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head There is no relevant literature to support the use of MRI head alone in the initial evaluation of children with suspected OPG. MRI of the head is, however, often obtained in conjunction with MRI orbits.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits Based on expert consensus, MRI orbits may be considered in cases of isolated OPG confined to the optic nerve and optic chiasm without NF-1.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Radiography Orbit There is no relevant literature to support the use of radiography orbit in the initial evaluation of children with suspected OPG.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Variant 6: Child. Six months of age or older. Papilledema detected on the ophthalmologic examination or signs of raised intracranial pressure. Initial imaging. This variant includes children (older infants or older children) presenting with signs and symptoms of raised intracranial hypertension (papilledema, headache, nausea, vomiting, or transient obscuration of vision) [40]. Increased intracranial pressure may be caused by intracranial structural lesions, like space occupying lesion or hydrocephalus. Idiopathic intracranial hypertension (IIH), or pseudotumor cerebri, is a syndrome defined by elevated intracranial pressure without evidence of a structural lesion or hydrocephalus on neuroimaging and a normal cerebrospinal fluid composition [41]. In postpubertal children, IIH is typically seen in overweight girls; however, in prepubertal children, boys and girls are equally affected [41]. Several secondary causes of pseudotumor cerebri have been described, including cerebral venous anomalies, intracranial arteriovenous fistulas, medications (tetracyclines, Vitamin A, retinoids, steroids, growth hormone, thyroxine, lithium, etc), and endocrine disorders (Addison disease, hypoparathyroidism, etc) [42]. Diagnostic criteria for pseudotumor cerebri syndrome include papilledema, normal neurological examination (except sixth nerve palsy), normal brain parenchyma on imaging (with absence of mass, hydrocephalus, or abnormal meningeal enhancement), normal cerebrospinal fluid composition, and elevated lumbar puncture opening pressure >280 mm of cerebrospinal fluid in children (or >250 mm cerebrospinal fluid if the child is not sedated and not obese) [42]. In the absence of papilledema and sixth nerve palsy, diagnosis of pseudotumor cerebri can be suggested on neuroimaging based on findings including empty sella, flattening of the posterior aspect of the globes, distention of the perioptic subarachnoid space, and transverse sinus stenosis [42]. This variant includes older infants or older children therefore head ultrasonography is not an optimal imaging option.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head and Orbits There is no relevant literature to support the use of CT head and orbits in the initial evaluation of children with papilledema or suspected raised intracranial pressure.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child CT Head CT of the head without IV contrast may be a useful and alternative modality to MRI head for the evaluation of intracranial space occupying lesion or hydrocephalus causing raised intracranial pressure and papilledema. There is no relevant literature to support the use of contrast-enhanced CT head in the initial evaluation of children with papilledema or suspected raised intracranial pressure.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits There is no relevant literature to support the use of CT orbits in the initial evaluation of children with papilledema or suspected raised intracranial pressure.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children with papilledema or suspected raised intracranial pressure.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTV Head CT venography (CTV) of the head may be an alternative to MR venography (MRV) for the evaluation of cerebral venous sinuses [42].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children with papilledema or suspected raised intracranial pressure.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head and Orbits MRI of the head and orbits is the most useful imaging modality for initial evaluation of the child presenting with papilledema and signs of raised intracranial pressure by detection of intracranial space occupying lesion or hydrocephalus. MRI is more useful over CT in children because of the ability of MRI to provide a higher resolution of intracranial and intraorbital structures [42,43]. Various neuroimaging findings in diagnosis of pediatric IIH are best assessed with MRI of the head and orbits. These include posterior globe flattening (56% sensitivity and 100% specificity), intraocular protrusion of the optic nerve (40% sensitivity and 100% specificity), and horizontal tortuosity of the optic nerve (68% sensitivity and 83% specificity). In the patients with IIH, optic nerve sheath was enlarged compared with those in the control group (mean 4.3 versus 3.2 mm), and pituitary gland size is found to be smaller in the patients with IIH compared with those in the control group (mean 3.63 versus 5.05 mm) [43]. Administration of IV contrast can help in characterization of the intracranial space occupying lesion (when detected).


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head MRI of the head may be useful for initial evaluation of the child presenting with papilledema and signs of raised intracranial pressure by detecting an intracranial space occupying lesion or hydrocephalus. MRI is more useful than CT because of its ability to provide a higher soft tissue contrast resolution of intracranial structures [42,43]. MRI can also aid in the diagnosis of IIH by demonstrating a finding of partially empty sella. However, other imaging findings of IIH are better evaluated on MRI of the orbits. Administration of IV contrast can help in characterization of the intracranial space occupying lesion (when detected).


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits There is no relevant literature to support the use of MRI orbits alone in the initial evaluation of children with papilledema or suspected raised intracranial pressure.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRV Head MRV of the head may be useful in demonstrating narrowing of the distal transverse sinuses, which is supportive of the diagnosis of IIH. It may also be helpful in excluding cerebral venous sinus thrombosis, which may be a cause of secondary pseudotumor cerebri, especially in nonobese prepubertal children and individuals at high risk of cerebral venous sinus thrombosis [42,43].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Variant 7: Child. Suspected orbital or periorbital infection. Initial imaging. This variant consists of children presenting with signs of orbital infection. These include preseptal cellulitis (when infection is confined to eyelids and soft tissues anterior to the orbital septum), postseptal cellulitis, and orbital abscess. Preseptal cellulitis is usually caused by percutaneous introduction of the infectious pathogen or secondary to sinusitis or odontogenic in origin. Postseptal cellulitis is usually secondary to sinusitis (particularly ethmoid sinusitis) [44,45]. Infection of the postseptal space may have various catastrophic complications including raised


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child orbital pressure, retinal artery/superior ophthalmic vein occlusion, optic nerve injury (leading to vision loss), cavernous sinus thrombosis, or empyema [46]. Clinical findings alone may not be specific enough to distinguish preseptal from orbital infections or those with complications. Proptosis and limitation of the extraocular movements are indicators of postseptal inflammation, but these are not very accurate and fail to differentiate postseptal inflammation from abscess [44]. Other risk factors for postseptal inflammation are high neutrophil count, the absence of infectious conjunctivitis, gross periorbital edema, age >3 years, and previous antibiotic therapy [44]. The primary role of imaging is to differentiate preseptal cellulitis from postseptal cellulitis and abscess. It also helps in identifying underlying sinusitis and intracranial complications of orbital infections.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head There is no relevant literature to support the use of CT head as the initial evaluation of children with suspected periorbital or orbital infection. CT head with IV contrast may be considered in cases in which intracranial complications of the orbital cellulitis (like subdural empyema or cavernous sinus thrombosis) are suspected [46]. Precontrast imaging is typically not necessary in evaluating these patients because they do not add significant diagnostic information in this scenario.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits CT of the orbits with IV contrast is considered the most useful imaging in cases of suspected orbital infection [46]. It aids in differentiation of preseptal cellulitis from postseptal cellulitis and abscess. It is also useful in detection of complications like superior ophthalmic vein/cavernous sinus thrombosis or subdural empyema [46]. Precontrast imaging is typically not necessary in evaluating these patients because they do not add significant diagnostic information in this scenario.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children with suspected periorbital or orbital infection.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of children with suspected periorbital or orbital infection. It may be useful in evaluation of cases in which cavernous sinus thrombosis is suspected as a complication of orbital cellulitis.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children with suspected periorbital or orbital infection.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head MRI of the head with and without IV contrast can be complementary to CT scan and may be considered if a more detailed assessment of intraorbital spread of infection is clinically warranted. It may be especially considered for cases in which there is clinical or CT-based suspicion for intracranial complications [46].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits MRI of the orbits and head with and without IV contrast can be complementary to CT scan and may be considered if a more detailed assessment of intraorbital spread of infection is clinically warranted. It may be especially considered for cases in which there is clinical or CT-based suspicion for intracranial complications [46].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of children with suspected periorbital or orbital infection. Suspected superior orbital vein or cavernous sinus thrombosis (as a complication of orbital cellulitis) may be better evaluated with MRI of brain and orbits with IV contrast rather than MRV.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Variant 8: Child. Leukocoria or suspected intraocular mass. Initial imaging. Leukocoria is defined as abnormal white reflection from the retina of the eye (compared with normal red reflection) and can be related to abnormalities of the lens, vitreous, or retina. In children, the common causes include retinoblastoma, persistent hyperplastic primary vitreous (PHPV), retinopathy of prematurity, Coats disease, congenital cataract, and larval granulomatosis. Diagnosis of most of these conditions is based on the clinical history, fundoscopic examination, and ocular US performed by the ophthalmologist and may not require additional imaging.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child CT Head and Orbits CT head and orbits with IV contrast may be helpful in differentiating various causes of leukocoria and also for the evaluation of the extension of retinoblastoma along optic nerves and intracranially.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Head CT head with IV contrast may be helpful as an adjunct to the orbital imaging for the evaluation of intracranial spread of retinoblastoma.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CT Orbits CT of the orbits with IV contrast may be helpful in differentiating various causes of leukocoria and also for the evaluation of the extension of the retinoblastoma along optic nerves.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of children with leukocoria or suspected intraocular or orbital mass.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of children with leukocoria or suspected intraocular or orbital mass.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Retinopathy of prematurity and PHPV are associated with microphthalmia compared to normal sized globe in Coats disease or retinoblastoma. Absence of calcification on CT scan is important to differentiate PHPV and Coats disease from retinoblastoma. Postcontrast enhancement of the intraocular mass on MRI also helps to differentiate retinoblastoma from Coats disease, PHPV, or retinopathy of prematurity [2].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Head MRI head with and without IV contrast may be useful as an adjunct to the orbital imaging for the evaluation of the intracranial extension of retinoblastoma. In situations in which a malignant intraocular or intraorbital mass (retinoblastoma) is suspected, this is best performed in association with the MRI of the orbits [48].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. MRI Orbits MRI of the orbits with and without IV contrast is useful in the initial evaluation of the benign intraorbital masses or other causes of leukocoria [2]. In situations in which a malignant intraocular or intraorbital mass (retinoblastoma) is suspected, this is best performed in association with the MRI of the brain to assess for possible intracranial spread of the tumor [48].


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Orbital Imaging and Vision Loss-Child Supporting Documents The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.


Orbital Imaging and Vision Loss Child

Orbital Imaging and Vision Loss Child. Appropriateness Category Names and Definitions Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging


Low Back Pain PCAs

Low Back Pain PCAs. Introduction/Background In the United States, acute low back pain (LBP), with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life years [1]. It is the fifth most common reason for a physician visit in the United States and accounts for approximately 3% of visits to the emergency department [2].


Low Back Pain PCAs

Low Back Pain PCAs. The American College of Physicians and the American Pain Society classify LBP into the following broad categories: nonspecific LBP, back pain potentially associated with radiculopathy or spinal stenosis, and back pain potentially associated with another specific spinal cause [3]. Additionally, guidelines from the American College of Physicians and the American Pain Society [3,4] emphasize a focused history and physical examination, reassurance, initial pain management medications if necessary, and consideration of physical therapies without routine imaging in patients with nonspecific LBP. Duration of symptoms also helps guide treatment algorithms in patients with acute, subacute, or chronic LBP. Additionally, assessment of psychosocial risk factors when obtaining patient history is a strong predictor of patients who are predisposed to developing chronic disabling LBP problems [3].


Low Back Pain PCAs

Low Back Pain PCAs. Although there is great variability in the definition of acute and subacute LBP, for the purposes of this guideline, we will use the Institute for Clinical Systems Improvement definitions of 0 to 4 weeks to define acute LBP, 4 to 12 weeks for subacute LBP, and >12 weeks for chronic LBP [5].


Low Back Pain PCAs

Low Back Pain PCAs. It is clear that uncomplicated acute LBP and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies [4,6,7]. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome (CES), malignancy, fracture, or infection (see Table 1).


Low Back Pain PCAs

Low Back Pain PCAs. aUniversity of Utah Health, Salt Lake City, Utah. bResearch Author, University of Utah Medical Center, Salt Lake City, Utah. cPanel Chair, University of Utah, Salt Lake City, Utah. dPanel Vice-Chair, Mallinckrodt Institute of Radiology, Saint Louis, Missouri. eUniversity of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. fThe Ohio State University Wexner Medical Center, Columbus, Ohio. gMontefiore Medical Center, Bronx, New York. hUK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons. iEmory University, Atlanta, Georgia. jUCLA Medical Center, Los Angeles, California; Neurosurgery expert. kMayo Clinic, Rochester, Minnesota. lJohns Hopkins Hospital, Baltimore, Maryland. mUniversity of Michigan, Ann Arbor, Michigan. nJacobi Medical Center, Bronx, New York. oRush University, Chicago, Illinois; Neurosurgery expert. pUniversity of North Carolina School of Medicine, Chapel Hill, North Carolina; American Academy of Neurology. qPennsylvania State University College of Medicine, Hershey, Pennsylvania; American College of Emergency Physicians. rMedical University of South Carolina, Charleston, South Carolina; North American Spine Society. sUniversity of California San Francisco, San Francisco, California. tIndiana University School of Medicine, Indianapolis, Indiana; American College of Physicians. uUniversity of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado. vSpecialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia.


Low Back Pain PCAs

Low Back Pain PCAs. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization.


Low Back Pain PCAs

Low Back Pain PCAs. Reprint requests to: publications@acr.org


Low Back Pain PCAs

Low Back Pain PCAs. Low Back Pain Table 1. Red Flags: Indications of a more complicated status include back pain/radiculopathy in the following settings (adapted from Bigos et al [8]).


Low Back Pain PCAs

Low Back Pain PCAs. Previous guidelines have suggested that imaging be performed in adults >50 years of age who present with LBP. When studied, there was no statistically significant difference in primary outcome after 1 year for patients aged 65 years or older who had spine imaging within 6 weeks after an initial visit for care for LBP versus similar patients who did not undergo early imaging [9]; thus, this document does not include >50 years of age as an independent red flag. However, an important age-related risk factor for spinal fracture presenting as LBP is osteoporosis. As bone mass decreases slowly over time, the prevalence of osteoporosis increases with age, and differs by sex, race, ethnicity [10], and comorbidities. In line with the US Preventive Services Task Force recommendations for patients ages 65 and older being screened for osteoporosis, patients >65 years of age may be considered at risk for osteoporotic fracture when presenting with LBP.


Low Back Pain PCAs

Low Back Pain PCAs. Additionally, for those patients without neurologic compromise and who present with minor risk factors for cancer, inflammatory back disease (eg, ankylosing spondylitis), vertebral compression fracture, or symptomatic spinal stenosis, imaging should be considered after a trial of therapy [4].


Low Back Pain PCAs

Low Back Pain PCAs. In the majority of patients, no specific pathology for LBP can be identified. Also, studies have shown imaging abnormalities in a substantial number of people without back pain [11-13]. The challenge for the clinician, therefore, is to distinguish the small segment within this large patient population that should be evaluated further because of suspicion of a more serious problem or identify pathology that requires intervention.


Low Back Pain PCAs

Low Back Pain PCAs. Nonspecific lumbar disc abnormalities are common in asymptomatic patients and can be demonstrated readily on MRI, CT, fluoroscopic myelography, and postmyelography CT of the lumbar spine [11]. Imaging abnormalities can be seen in a substantial number of people without back pain [11-13]. A prospective study by Carragee et al [13] found that among patients with lumbar imaging abnormalities before the onset of LBP, 84% had unchanged or improved findings after symptoms developed. A systematic review of 33 articles found an increasing prevalence of degenerative spine findings in asymptomatic patients of increasing age [12]. For example, disc protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age in this asymptomatic population. A prospective cohort study of 20 patients showed no significant differences in MRI changes over 12 months in patients presenting with acute LBP compared with their asymptomatic counterparts, except in disc herniation, nerve root compression, and annular fissure [15]. Even in the setting of disc herniation, imaging may have limited role in management as the majority of disc herniations show some degree of reabsorption or regression by 8 weeks after symptom onset [16]. It is important to note that repeat imaging in patients with new episodes of LBP and previous MRI scans are unlikely to detect differences in disc protrusion, annular fissures, high-intensity zones, or end-plate signal changes [13].


Low Back Pain PCAs

Low Back Pain PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Complete Spine There is no relevant literature to support the use of bone scan with single-photon emission CT (SPECT) or SPECT/CT in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain PCAs. CT Lumbar Spine With IV Contrast There is no relevant literature to support the use of CT lumbar spine with intravenous (IV) contrast in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain PCAs. CT Lumbar Spine Without and With IV Contrast There is no relevant literature to support the use of CT lumbar spine without and with IV contrast in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain PCAs. CT Myelography Lumbar Spine There is no relevant literature to support the use of lumbar spine CT myelography in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain

Low Back Pain PCAs. Low Back Pain


Low Back Pain PCAs

Low Back Pain PCAs. Discography and Post-Discography CT Lumbar Spine There is no relevant literature to support the use of discography with post-discography CT in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain PCAs. FDG-PET/CT Whole Body There is no relevant literature to support the use of whole-body fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG)- PET/CT in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain PCAs. MRI Lumbar Spine With IV Contrast There is no relevant literature to support the use of MRI lumbar spine with IV contrast in the initial evaluation of acute uncomplicated LBP.


Low Back Pain PCAs

Low Back Pain PCAs. Bone Scan Whole Body with SPECT or SPECT/CT Complete Spine There is no relevant literature to support the use of bone scan with SPECT or SPECT/CT in the initial evaluation of subacute or chronic LBP without red flags or prior management.


Low Back Pain PCAs

Low Back Pain PCAs. CT Lumbar Spine With IV Contrast There is no relevant literature to support the use of CT lumbar spine with IV contrast in the initial evaluation of subacute or chronic LBP without red flags or prior management.


Low Back Pain PCAs

Low Back Pain PCAs. CT Lumbar Spine Without and With IV Contrast There is no relevant literature to support the use of CT lumbar spine without and with IV contrast in the initial evaluation of subacute or chronic LBP without red flags or prior management.