Acute Trauma to the Knee

Acute Trauma to the Knee. Variant 4: Skeletally immature child. Fall or acute twisting trauma to the knee. No fracture seen on radiographs. Suspect occult fracture or internal derangement. Next study. CT Knee With negative radiographs, CT may be performed as the next imaging study for the evaluation of suspected radiographically occult knee fractures [12] and bone marrow contusions [16-18]. CT may diagnose or predict ligamentous injuries [14,15,50,51] and predict meniscal [15,50,51] injuries. However, MRI is superior to CT in evaluation of bone marrow lesions [27-29], meniscal [21,26] and ligamentous [21,31-34] injuries, and may be subsequently performed as clinically indicated.


Acute Trauma to the Knee

Acute Trauma to the Knee. MR Arthrography Knee With negative radiographs, MR arthrography is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRA Knee With negative radiographs, MRA is not routinely used as the next imaging study for the evaluation of suspected occult knee fractures or internal derangement.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRI Knee MRI should be the next imaging modality to evaluate for the presence of radiographically occult fractures and/or internal derangements of the acutely injured knee. With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31-34].


Acute Trauma to the Knee

Acute Trauma to the Knee. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement.


Acute Trauma to the Knee

Acute Trauma to the Knee. Even-Sapir et al [37] showed promising results of a SPECT study in diagnosis of the ACL and meniscal tears and the associated bone contusions in patients with acute knee trauma with arthroscopic and MRI correlation. However, a more recent SPECT study with arthroscopic correlation by Wertman et al [39] showed a lower sensitivity, specificity, and accuracy than MRI in evaluating meniscal injuries.


Acute Trauma to the Knee

Acute Trauma to the Knee. US Knee US would not be the next best imaging study to evaluate for radiographically occult fractures and/or internal derangement of the acutely injured knee. However, US may demonstrate a lipohemarthrosis, indicating the presence of an intra-articular fracture [40]. US is an excellent imaging modality for the diagnosis of quadriceps tendon tears [42] with good performance in the evaluation of the meniscal [44-46] and ligamentous [47-49] injuries. However, the utility of US in the evaluation of the knee menisci, cruciate and collateral ligaments, and periarticular soft tissues varies depending on patient factors.


Acute Trauma to the Knee

Acute Trauma to the Knee. Variant 5: Adult or child 5 years of age or older. Fall or acute twisting trauma to the knee. Tibial plateau fracture on radiographs. Suspect additional bone or soft-tissue injury. Next study. CT Knee In patients with radiographic diagnosis of the tibial plateau fracture, CT is frequently performed for further classification and characterization of the fracture severity [12,52] and may predict or diagnose ligamentous injuries [13-15,50,51] and predict meniscal injuries [15,50]. A study by Spiro et al [50] found that the amount of articular surface depression on CT is a predictor of meniscal and ligamentous injuries and can suggest when an MRI is indicated to confirm or exclude meniscal and ligamentous injuries [50]. In a study by Mustonen et al [12], CT showed 100% sensitivity and radiographs 83% sensitivity in detection of tibial plateau fractures, and CT was superior in further characterization of fracture severity. Chang et al [52] reported that CT-reconstructed images


Acute Trauma to the Knee

Acute Trauma to the Knee

Acute Trauma to the Knee. Acute Trauma to the Knee


Acute Trauma to the Knee

Acute Trauma to the Knee. enhance the morphological subclassification of the medial tibial plateau fractures (Schatzker type IV) with common involvement of posterolateral quadrants. In the setting of acute knee trauma, Mui et al [13] reported 80% sensitivity and 98% specificity of the CT examination in detecting bony avulsion fractures. Tang et al [51] found that lateral tibial plateau depression of >11 mm and its specific part involvement on preoperative CT scans could help predict a higher risk of the lateral meniscus tear and the ACL avulsion fracture.


Acute Trauma to the Knee

Acute Trauma to the Knee. MR Arthrography Knee With a radiographic diagnosis of tibial plateau fracture, MR arthrography of the knee is not performed to evaluate for additional bone or soft-tissue injury.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRA Knee With a radiographic diagnosis of tibial plateau fracture, MRA of the knee is not performed to evaluate for additional bone or soft-tissue injury.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRI Knee With a radiographic diagnosis of tibial plateau fracture, MRI would be the next best imaging modality to evaluate for the presence of additional radiographically occult fractures and/or internal derangements of the acutely injured knee. With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31-34].


Acute Trauma to the Knee

Acute Trauma to the Knee. Bone Scan with SPECT or SPECT/CT Knee With a radiographic diagnosis of tibial plateau fracture, Tc-99m bone scan with SPECT/CT is not performed as the next best imaging study to evaluate for additional bone or soft-tissue injury.


Acute Trauma to the Knee

Acute Trauma to the Knee. US Knee With a radiographic diagnosis of tibial plateau fracture, US is not performed as the next best imaging study to evaluate for additional bone or soft-tissue injury.


Acute Trauma to the Knee

Acute Trauma to the Knee. Variant 6: Adult or child 5 years of age or older. Acute trauma to the knee. Mechanism unknown. Focal patellar tenderness, effusion, able to walk. Initial Imaging. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee but is superior to knee radiographs in detection and classification of fractures [12].


Acute Trauma to the Knee

Acute Trauma to the Knee. MR Arthrography Knee MR arthrography is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRA Knee MRA is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRI Knee MRI is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. MRI aids in diagnosis and further characterization of bone and soft-tissue injuries associated with transient lateral dislocation of the patella [53-55].


Acute Trauma to the Knee

Acute Trauma to the Knee. Bone Scan with SPECT or SPECT/CT Knee Tc-99m bone scan with SPECT/CT knee is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee.


Acute Trauma to the Knee

Acute Trauma to the Knee. US Knee US is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee.


Acute Trauma to the Knee

Acute Trauma to the Knee


Acute Trauma to the Knee

Acute Trauma to the Knee. Variant 7: Adult or child 5 years of age or older. Significant trauma to the knee (eg, motor vehicle accident, knee dislocation). Initial imaging. Arteriography Lower Extremity Vascular injury may be found in about 30% of patients following posterior knee dislocation [56]. Injuries of the popliteal artery require prompt surgical intervention to help limb preservation. Associated peroneal and tibial nerve injuries may cause significant morbidity and require an understanding of their pathophysiologic implications to maximize limb functionality [57]. Angiography has been the reference standard in the evaluation of vascular injuries associated with knee dislocations [58]. However, this is an invasive procedure with associated risk, and with the excellent performance of CTA and MRA, it is usually performed in selected cases [58].


Acute Trauma to the Knee

Acute Trauma to the Knee. CT Knee CT is not routinely used as the initial imaging study for the evaluation of acute trauma to the knee. CT is superior to knee radiographs in detection and classification of fractures [12]; however, without IV contrast, CT cannot detect vascular injuries.


Acute Trauma to the Knee

Acute Trauma to the Knee. CTA Lower Extremity With suspected vascular injuries in the setting of knee dislocation, CTA is frequently used because it is less invasive and has a similarly high accuracy as conventional angiography [58-60].


Acute Trauma to the Knee

Acute Trauma to the Knee. MR Arthrography Knee In patients with significant acute knee trauma with suspected or possible dislocation, MR arthrography of the knee is not routinely used as the initial imaging study.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRA Knee MRI is an accurate method used in the evaluation of soft-tissue, osseous, and neural injuries after knee dislocation [61]. MRA may be performed simultaneously with MRI for evaluation of internal derangement and vascular injuries with less morbidity compared with conventional angiography [62]. Potter et al [61] reported their experience with popliteal fossa MRA with encouraging results and complete agreement between the MRA and conventional angiography in patients who had both studies. Similarly, in a study by Tocci et al [62], MRA has been shown to be as accurate and useful as conventional angiography in the evaluation of popliteal artery injuries of patients with knee dislocations.


Acute Trauma to the Knee

Acute Trauma to the Knee. MRI Knee With its superb contrast resolution and multiplanar imaging capability, MRI is proven to be a highly accurate imaging modality in the evaluation of bone marrow contusions and occult fractures [27-29] as well as meniscal [21,26] and ligamentous injuries [21,31,32]. It can be performed in conjunction with MRA for evaluation of internal derangement and vascular injuries with less morbidity compared with conventional angiography [62].


Acute Trauma to the Knee

Acute Trauma to the Knee. Bone Scan with SPECT or SPECT/CT Knee In patients with significant acute knee trauma with suspected/possible dislocation, Tc-99m bone scan with SPECT/CT is not routinely used as the initial imaging study.


Acute Trauma to the Knee

Acute Trauma to the Knee. US Knee In patients with significant acute knee trauma with suspected or possible dislocation, US is not routinely used as the initial imaging study.


Acute Trauma to the Knee

Acute Trauma to the Knee. 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.


Acute Trauma to the Knee

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


Acute Trauma to the Knee

Acute Trauma to the Knee

Acute Trauma to the Knee. Acute Trauma to the Knee


Right Lower Quadrant Pain

Right Lower Quadrant Pain. Introduction/Background Right lower quadrant (RLQ) abdominal pain accounts for nearly 50% of patients presenting to the emergency department with abdominal pain [1]. Appendicitis is the most common surgical pathology responsible for RLQ abdominal pain in the United States [1,2]. Other less frequent causes of RLQ pain include right colonic diverticulitis, ureteral stone, colitis, and intestinal obstruction [1,3,4]. Imaging remains the diagnostic mainstay in the workup of patients presenting with RLQ abdominal pain for evaluation of suspected appendicitis and diagnosis of other conditions. Buckius et al [2] reported an annual increase in the rate of acute appendicitis in the United States; however, Ferris et al [5], in a recent systematic review of population-based studies, showed that although the incidence of both perforated and nonperforated appendicitis is stable in North America, the incidence is rising in newly industrialized countries. Historically, the clinical determination of appendicitis has been poor, particularly in special patient populations, such as those at the extremes of age and pregnant women. The negative appendectomy rate (NAR) based on clinical determination alone without imaging is unacceptably high, as high as 25% [6]. Clinical decisions tools, such as the Alvarado score (AS), have not improved the outright diagnostic accuracy of the clinical examination [7] and demonstrate mixed results as an adjunct to help guide CT use [8,9]. The decrease in NAR with increased imaging utilization is not accompanied by an increase in perforations from any introduced delays [10,11].


Right Lower Quadrant Pain

Right Lower Quadrant Pain. The choice of imaging modality should be tailored for diagnosis of acute appendicitis in patients with a high degree of suspicion but should also allow diagnosis of other causes of RLQ pain to triage appropriate patient management. In patients with suspected appendicitis, modalities should demonstrate high accuracy, which allows for 1) the confident (and presumed early) diagnosis in positive cases, reducing delays in diagnosis and perforation with attendant morbidity and mortality; 2) the confident exclusion of the diagnosis in negative cases with a decrease in the NAR and the attendant potential surgical complications; and 3) the confident diagnosis of alternative diagnoses, in many cases.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Introduction/Background Chronic hip pain is a common chief complaint for patients, reportedly affecting 30% to 40% of adults who play sports [1,2], and 12% to 15% of all adults over 60 [3,4]. A wide variety of pathological entities may cause hip pain, including osseous as well as intra- or extra-articular soft tissue abnormalities [5-7]. Pathology involving the lumbar spine, sacroiliac, or knee joints can also cause hip pain [8], and these etiologies should be investigated as needed. There is limited original research that specifically targets the imaging of chronic hip pain, but imaging of specific conditions is widely discussed in the published literature.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. OR 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.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Reprint requests to: publications@acr.org


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Chronic Hip Pain Discussion of Procedures by Variant Variant 1: Chronic hip pain. Initial Imaging. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Arthrography Hip There is no relevant literature to support the use of CT arthrography of the hip in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with intravenous (IV) contrast in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without IV Contrast There is no relevant literature to support the use of CT of the hip without IV contrast in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures There is no relevant literature to support the use of image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip There is no relevant literature to support the use of MR arthrography of the hip in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast There is no relevant literature to support the use of MRI of the hip without and with IV contrast in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast There is no relevant literature to support the use of MRI of the hip without IV contrast in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Radiography Hip The literature indicates that radiography is a first-line screening tool, and hip radiographs are useful in the initial imaging workup of chronic hip pain [12]. Oftentimes a pelvic radiograph, which includes imaging of both hips, may be obtained concurrently with additional dedicated collimated radiograph(s) of the affected hip(s). Findings on hip radiographs can result in an imaging diagnosis such as osteoarthritis or can lead to more advanced workups of less common causes of chronic hip pain such as primary bone tumors. The results of screening hip radiographs can help guide the use of additional imaging studies such as more specialized radiographic views or more advanced modalities such as CT, ultrasound (US), MRI, radionuclide bone scans, and fluoride PET [13-15].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Radiography Pelvis The literature indicates that radiography is a first-line screening tool, and pelvic radiographs are useful in the initial imaging workup of chronic hip pain [12]. A pelvic radiograph is an excellent initial examination because it allows for evaluation of both hip joints on a single radiographic image, allowing for comparison of the ipsilateral and contralateral hips. Oftentimes, a pelvic radiograph may be obtained concurrently with additional dedicated radiograph(s) of the affected hip. Findings on pelvic radiographs can result in an imaging diagnosis such as osteoarthritis or may lead to more advanced workups of less common causes of chronic hip pain such as primary bone tumors. The results of the pelvic radiograph can help the clinician for the selection of additional imaging techniques and for comparison with studies such as MRI, CT, radionuclide bone scans, and fluoride PET [13-15].


Chronic Hip Pain PCAs

Chronic Hip Pain

Chronic Hip Pain PCAs. Chronic Hip Pain


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip There is no relevant literature to support the use of US hip in the initial evaluation of chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Variant 2: Chronic hip pain. Suspect noninfectious extra-articular abnormality, such as tendonitis or bursitis. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the evaluation of extra-articular soft tissue abnormalities.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Arthrography Hip The instillation of intra-articular contrast may elucidate periarticular soft tissue abnormalities such as labral or capsular pathology [16-18]. However, CT arthrography is limited for evaluating the extra-articular soft tissue pathology because of the inherent poor soft tissue contrast of CT. Within the limitation of CT; however, some extra- articular pathologic entities, such as a large, distended bursa may be evident on CT. Tendinous pathology is not particularly well depicted on CT.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast in the evaluation of tendon or bursal pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast in the evaluation of tendon or bursal pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without IV Contrast CT hip without IV contrast is of limited use in the evaluation of extra-articular soft tissue pathology because of the inherent poor soft tissue contrast of CT [18]. Within the limitation of the contrast resolution of CT, some extra- articular pathologic entities, such as a large, distended bursa may be evident on CT. Tendinous pathology is not well evaluated on CT.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to a noninfectious extra-articular abnormality.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip There is no relevant literature to support the use of MR arthrography in the evaluation of extra-articular soft tissue pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast There is no relevant literature to support administration of IV contrast (gadolinium chelate agents) for routine MRI of the hip.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast MRI without IV contrast is useful for evaluating soft tissues given its high soft tissue contrast resolution [23]. Numerous studies have demonstrated that MRI is both highly sensitive and specific for evaluation of the articular and periarticular soft tissues [24]. As such, noncontrast MRI should be considered as the next imaging test following radiographic evaluation of the hip joint [25-34]. Trochanteric, iliopsoas, ischial, and subiliacus bursitis are well demonstrated on noncontrast MRI, as are abductor and adductor tendinosis and tears, hamstring injuries, athletic pubalgia, and calcific tendinosis. Large field-of-view images obtained as part of a hip MRI can also sometimes


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip The literature indicates that US is useful for the evaluation of extra-articular soft tissues in the region of the hip [23]. US can also nicely demonstrate fluid collections around the hip, such as bursitis and paralabral cysts. Tendon pathology, such as tendinosis, tears, or snapping iliopsoas tendons can also be identified with US [38-41]. US may also be useful for the dynamic evaluation of the iliopsoas tendon, such as in snapping hip syndrome.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Variant 3: Chronic hip pain. Suspect impingement or dysplasia. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support to the use of bone scan of the hip in the evaluation of suspected hip impingement.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Arthrography Hip Pathology associated with femoracetabular impingement (FAI) may be both intra- and extra-articular. CT is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. CT arthrography has been shown to be sensitive for detection of acetabular labral tears [17], which may be associated with FAI. CT arthrography has also been shown to be more helpful in identifying chondral lesions [16] when compared to MRI. However, arthrography does not offer an advantage over noncontrast CT for the detection of extra-articular impingement (eg, ischiopelvic, ischiotrochanteric, subspinous, and femoropelvic).


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast CT without IV contrast is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. However, IV contrast administration does not confer an additional advantage for evaluation of hip impingement.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast Noncontrast CT is often used for preoperative assessment of bony anatomy in the setting of FAI and hip dysplasia [42-44]. IV contrast administration is not warranted for evaluation of hip impingement.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh One study demonstrated the potential use of fluoride PET to demonstrate increased bone turnover in the setting of chronic hip pain and FAI [50]. One other study demonstrated that fluoride PET can demonstrate acetabular contrecoup injuries in patients with FAI [51]. However, increased radiotracer uptake is a nonspecific finding, and, overall, there is insufficient literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to hip impingement and/or dysplasia.


Chronic Hip Pain PCAs

Chronic Hip Pain

Chronic Hip Pain PCAs. Chronic Hip Pain


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip Direct MR arthrography, performed following the intra-articular injection of a 1:200 solution of gadolinium chelate in saline, is useful for diagnosing acetabular labral tears [65-70] that are frequently associated with FAI [71,72] and/or hip dysplasia. MR arthrography has been shown to have a sensitivity of 94.5% and a specificity of 100% for the detection of labral tears [52], which may be associated with FAI. Some authors have shown that MRI without IV contrast and MR arthrography are similarly accurate and sensitive for detecting labral tears in the setting of FAI [53], and other authors have shown that MR arthrography is superior to conventional MRI [54,55]. Several publications show that MR arthrography is superior to CT arthrography and noncontrast MRI for evaluation of labral tears [18,56], but there are other publications that demonstrate that CT arthrography and noncontrast MRI are superior [16,57-59]. MR arthrography may also nicely demonstrate acetabular chondral delamination [60]. Although MR arthrography can be useful for demonstrating labral and chondral pathology associated with impingement, the presence of intra-articular contrast offers no advantage over noncontrast MRI for the detection of extra-articular abnormalities associated with impingement.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast Indirect arthrography is a technique that falls under the category of MRI hip with contrast. When administered intravenously, gadolinium chelate contrast can diffuse into the joint space via the synovium, and this results in indirect arthrography. There is limited literature supporting the use of indirect arthrography instead of direct MR arthrography for evaluating intra-articular disorders [34,61-63]. IV, rather than intra-articular, injection of contrast is faster and easier to perform and does not require image guidance, but indirect arthrography does not distend the joint capsule and results in less consistent enhancement of the joint space. The accuracy of indirect arthrography for evaluation of the acetabular labrum and articular cartilage remains uncertain. Because the literature supporting indirect arthrography is scant, it is a technique that is not often used clinically.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI without IV contrast is useful for evaluating the labrum and articular cartilage in the setting of FAI and/or dysplasia. It can even be used for the detailed assessment of osseous anatomy, such as the shape and contour of the femoral neck. A noncontrast MRI can demonstrate findings of extra-articular impingement as well. At times, indirect arthrography may be performed following noncontrast image acquisition in order to obtain a complementary assessment of the hip and its synovium.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast FAI and dysplasia are associated with both intra- and extra-articular abnormalities, both osseous and soft tissue. The literature demonstrates that a noncontrast MRI is useful in the assessment of labral and cartilage lesions in the setting of hip impingement. Investigators have demonstrated success in detecting labral and articular cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast [58,68]. Additional literature has shown that high-resolution 3T MRI without IV contrast can further improve the visualization of the acetabular labrum and the articular cartilage of the femoral head and acetabulum [69,70].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Evaluation of cortical bone is more difficult with conventional MRI than it is with CT, but the use of isotropic MR sequences has been shown to be effective in the evaluation of FAI [71]. Some centers routinely evaluate the shape and contours of the femoral neck by utilizing radial imaging or radial reconstructions. Additional research has shown that the zero-echo time pulse sequence offers excellent visualization of cortical bone on MRI without the need for contrast, and it has been shown to be an effective sequence for evaluating osseous hip morphology [72].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI can also be useful in detecting extra-articular impingements (ischiopelvic, ischiotrochanteric, subspinous, and femoropelvic) [45,46].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Although there is a paucity of supportive data, some surgeons may use both MRI and CT in order to define the soft tissues (labrum and articular cartilage) and the bone, respectively. Measurements can be performed on radiography, CT, and MRI [42-44,47,48].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Radiography Hip Additional Views For further evaluation of disorders such as dysplasia or FAI, specialized views such as the false profile or elongated femoral neck lateral (Dunn) views can provide more detailed evaluation of the anatomy of the femoral head and neck and the degree of acetabular coverage of the femoral head [47].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip In general, US is limited in its use for evaluating osseous structures. However, there is limited literature that demonstrates that US can be used to evaluate osseous features of FAI such as the alpha-angle [73]. However, US is not able to adequately evaluate osseous abnormalities deep to the cortex. One of the advantages of US is its ability to dynamically evaluate for extra-articular soft tissue impingement. US is not as sensitive as MRI or CT arthrography for the detection of labral tears [17], but it can be useful for the detection and localization of paralabral cysts for aspiration and injection [39,41].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Variant 4: Chronic hip pain. Suspect labral tear. Radiographs negative or nondiagnostic. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip for the workup of an acetabular labral tear in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Arthrography Hip Some authors have shown that CT arthrography can be useful in the detection of acetabular labral tears [17,74], which may be associated with FAI, but other authors have shown that CT arthrography is not very good for the detection of labral tears [18].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast There is no relevant literature to support the use of CT hip without and with IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without IV Contrast Because of its inherent poor contrast resolution, there is no relevant literature supporting the use of CT hip without IV contrast for the workup of an acetabular labral tear in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the evaluation of chronic hip pain thought to be due to a labral tear.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures Diagnostic joint injections are safe and useful tools for confirming the etiology of pain, such as a labral tear or symptomatic paralabral cyst [20-22].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip Direct MR arthrography, with the intraarticular injection of a 1:200 solution of gadolinium chelate in saline, has been established as a reliable technique for diagnosing acetabular labral tears [75-80] that are frequently associated with FAI [81,82]. MR arthrography has been shown to have a sensitivity of 94.5% and a specificity of 100% for the detection of labral tears [52]. Within some of the published literature, MR arthrography has often been demonstrated to be superior to CT arthrography and noncontrast MRI for evaluation of labral tears [18,56]. However, in other articles, CT arthrography and noncontrast MRI fare better [16,57-59].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast Indirect arthrography is a technique that falls under the category of MRI hip with contrast. For performance of indirect MR arthrography, gadolinium chelate contrast is administered by IV injection and diffuses into the joint space through the synovium. This technique has been proposed as an alternative to direct MR arthrography for detecting intra-articular disorders [34,61-63] because it is faster and easier to perform than direct arthrography and does not require image guidance. However, indirect arthrography offers less consistent enhancement of the joint space and cannot distend the joint capsule. Although the literature is scant, there are a few small studies suggesting


Chronic Hip Pain PCAs

Chronic Hip Pain

Chronic Hip Pain PCAs. Chronic Hip Pain


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. that indirect MR arthrography may be helpful in detecting labral pathology [83,84]. However, as the literature supporting indirect arthrography is very limited, it is a technique that is not often used clinically.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast MRI is currently the reference standard for evaluation of labral pathology [85]. For evaluating labral tears, MRI with or without arthrography can be used [76-79]. Several investigators suggest that high-resolution 3T MRI may improve the visualization of the acetabular labrum and the hyaline articular cartilage [69,70], which may obviate the need for intra-articular contrast [86]. Other investigators have obtained satisfactory results in detecting labral and hyaline cartilage lesions with high-resolution MRI of the hip at 1.5T without intra-articular contrast [58,68].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip Although not as commonly used as MRI for the detection of labral pathology, US has been able to document the presence of labral tears in patients with hip pain [87,88]. However, it is not as sensitive as other modalities for detecting labral tears [17]. US can also be used to localize paralabral cysts for aspiration and injection [39,41].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Variant 5: Chronic hip pain. Radiographs equivocal or positive for mild osteoarthritis. Evaluate articular cartilage integrity. Next imaging study. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the assessment of the extent of cartilage damage in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Arthrography Hip Direct visualization of articular cartilage is possible using those imaging techniques that provide either intrinsic contrast (MRI and US) or extrinsic contrast (any type of arthrography) [89]. Hip cartilage abnormalities can be successfully evaluated by high-resolution CT arthrography [18,90-93], thus allowing for improved assessment of the degree of cartilage loss when compared with the initial radiographs.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip with IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip without and with IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without IV Contrast Because of its inherent poor soft tissue contrast resolution, there is no relevant literature to support the use of CT hip without IV contrast in the assessment of the extent of cartilage damage in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the assessment of the extent of cartilage damage in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures Although image-guided anesthetic and/or corticosteroid injections may be useful in the diagnosis and treatment of patients with osteoarthritis, it does not offer the possibility of evaluating the extent of cartilage damage that may exist in a joint. Image-guided therapeutic injections have not been shown to alter patient reported outcome measures [94].


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip Direct visualization of articular cartilage is possible on MRI because of its intrinsic excellent soft tissue contrast resolution. Intra-articular administration of contrast can also help with the direct visualization of articular cartilage [89]. MR arthrography has been shown to have high sensitivity and fair specificity of 92.5% and 54.5%, respectively, for the detection of chondral pathology in the setting of FAI [52]. A lower sensitivity for the detection of chondral pathology has been reported for the detection of hip articular cartilage defects in a more generalized group of patients [55]. Assessment of the T2* relaxation time is not affected by the presence of intra-articular gadolinium injection [95], and, although more commonly used for research purposes, T2* may be used to assess cartilage ultrastructure.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast Indirect arthrography falls under the technique of MRI hip with IV contrast. The diagnostic accuracy of indirect MR arthrography has not been widely studied [96], and, as such, there is insufficient literature to support the use of MRI with IV contrast in assessment for the degree of cartilage damage. IV contrast administration can; however, help to demonstrate the degree of enhancing inflamed synovium. Delayed gadolinium-enhanced MRI of cartilage may be useful in assessing the degree of hip cartilage damage, but this is most frequently employed in the research setting [97]. Overall, given the scant literature supporting indirect arthrography, this is a technique that is not often used clinically.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast Direct visualization of articular cartilage is possible on MRI because of its intrinsic excellent soft tissue contrast resolution [89]. MRI can demonstrate the articular cartilage and areas of chondral pathology [18,91,93]. MRI has been shown to be 85.92% accurate for identification of acetabular chondral rim lesions when compared to arthroscopy [85]. Various MRI techniques such as T2 mapping, T1rho, and sodium imaging allow for the ultrastructural assessment of articular cartilage [98]. Although these techniques are primarily used in the research setting, some have also been applied in the routine evaluation of clinical patients.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip US is limited in the hip by its inability to evaluate the acetabular or the majority of the femoral head cartilage. The acoustic window to see articular cartilage in the hip is limited.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Variant 6: Chronic hip pain. Radiographs suspicious for intra-articular synovial hyperplasia or neoplasia including nodular synovitis, diffuse tenosynovial giant cell tumor, osteochondromatosis, other synovial neoplasm. Next imaging study. Image-Guided Aspiration Hip Image-guided aspiration/injections demonstrate brown or bloody aspirate in patients with the diffuse form of tenosynovial giant cell tumor [99,100]. The diagnosis of synovial hyperplasia/neoplasia may require a tissue sample.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Bone Scan Hip There is no relevant literature to support the use of bone scan of the hip in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Arthrography Hip CT arthrography may be helpful in evaluating whether there are intra-articular bodies or hypertrophic synovium.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast There is no relevant literature to support the use of CT hip with IV contrast for the workup of synovial hyperplasia/neoplasia in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast It can be quite difficult to distinguish diffuse tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes on imaging. CT without IV contrast might help to detect calcification. However, there is no added benefit of administering IV contrast for the diagnosis of a synovial proliferative process.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without IV Contrast Intra-articular sources of pain such as synovitis, whether inflammatory (eg, Lyme disease), proliferative (eg, synovial chondromatosis), or neoplastic (eg, chondroma), are well demonstrated on MRI. It can be quite difficult to distinguish tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes, although CT might help to detect subtle calcifications, which can sometimes be seen with synovial chondromatosis but are not typically seen in the setting of tenosynovial giant cell tumor.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh There is no relevant literature to support the use of fluoride PET/CT skull base to mid-thigh in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Image-Guided Anesthetic +/- Corticosteroid Injection Hip Joint or Surrounding Structures There is no relevant literature to support the use of image-guided anesthetic +/- corticosteroid injection hip joint or surrounding structures in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain

Chronic Hip Pain PCAs. Chronic Hip Pain


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip Instillation of intra-articular contrast may be helpful in elucidating whether a body/bodies are intra-articular. However, in cases in which precise intra-articular pathology is still unknown and neoplasm remains a consideration, histologic sampling of the neoplastic process is probably indicated before instillation of contrast into the joint to avoid unintended harm.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast MRI hip with IV contrast administration may be helpful in distinguishing enhancing inflamed synovium from a bland joint effusion.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast Intra-articular sources of pain such as synovitis, whether inflammatory (eg, Lyme disease), proliferative (eg, synovial chondromatosis), or neoplastic (eg, chondroma), are well demonstrated on MRI. It can be quite difficult to distinguish tenosynovial giant cell tumor from synovial chondromatosis and other proliferative synovial processes. MRI, including a gradient-echo sequence, may be useful in assessing for blooming, which would indicate the presence of hemosiderin, such as can be seen in tenosynovial giant cell tumor.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip There is no relevant literature to support the use of diagnostic US hip in the assessment of the intra-articular synovial hyperplasia/neoplasia in a patient with chronic hip pain.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Variant 7: Chronic hip pain with low back or knee pathology or pain. Radiographs demonstrate hip osteoarthritis. Want to quantify amount of pain related to the hip. Next imaging study. Bone Scan Hip Although a bone scan of the hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip With IV Contrast Although CT hip with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without and With IV Contrast Although CT hip without and with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. CT Hip Without IV Contrast Although CT hip without IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. Fluoride PET/CT Skull Base to Mid-Thigh Although fluoride PET/CT skull base to mid-thigh may be able to demonstrate pathology about the hip, knee, and spine, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MR Arthrography Hip Although MR arthrography hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology. If anesthetic is mixed with the contrast that is injected


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without and With IV Contrast Although MRI hip without and with IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. MRI Hip Without IV Contrast Although MRI hip without IV contrast may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. US Hip Although US hip may be able to demonstrate pathology about the hip, it cannot be used to quantify the amount pain that is generated from the hip pathology.


Chronic Hip Pain PCAs

Chronic Hip Pain PCAs. 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.


Chronic Hip Pain PCAs

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


Ataxia Child

Ataxia Child. Specific manifestations of ataxia may correspond to certain causes or may be discovered by particular triggers. For example, truncal ataxia is typical of cerebellar vermian pathology [1]. A lurching gait, when triggered by head rotation, is typical of vestibular dysfunction [9]. Sensory ataxia can be revealed by a positive Romberg test, which examines the dorsal columns. [9]. Additionally, ataxia with specific signs can suggest the underlying disorder. Pupillary abnormalities may suggest drug or toxin ingestion versus third cranial nerve compression. Torticollis or resistance to head and neck motion may indicate pathology at the craniocervical junction, cord compression, or posterior fossa tumor [9].


Ataxia Child

Ataxia Child. Based on a systematic review of European data, the estimated prevalence of childhood ataxia due to genetic and acquired causes is approximately 26 per 100,000 children, although the true worldwide prevalence may be higher [10]. Regional variations exist in the prevalence of childhood ataxia, with a higher prevalence of genetic causes of ataxia in countries with high consanguinity, and a higher prevalence of infectious causes such as malaria and varicella in other regions where these diseases are more common [10].


Ataxia Child

Ataxia Child. Evaluation of ataxia requires careful review of demographics, history (especially duration of symptoms and the presence of additional neurological deficits), clinical examination, laboratory testing, and neuroimaging to reach a cohesive diagnosis [2,7,11-13]. In young children and infants, a detailed neurological examination is often challenging, and initial imaging therefore plays a critical role in arriving at a diagnosis.


Ataxia Child

Ataxia Child. The time course of illness (eg, acute, recurrent, chronic with or without progression) may indicate or rule out potential etiology. Acute onset ataxia typically refers to ataxia that develops within hours or days and frequently presents within 72 hours, whereas chronic ataxia is defined as ataxia lasting longer than 2 months [1,14]. Acutely presenting ataxia in children may be due to infectious, inflammatory, toxic, ischemic, or traumatic etiology. Intermittent or episodic ataxia in children may be manifestations of migraine, benign positional vertigo, or intermittent metabolic disorders. Whereas nonprogressive childhood ataxia suggests a congenital brain malformation or early prenatal or perinatal brain injury, progressive childhood ataxia may be due to inherited causes or acquired posterior fossa lesions that result in gradual cerebellar dysfunction.


Ataxia Child

Ataxia Child. Reprint requests to: publications@acr.org


Ataxia Child

Ataxia Child. Although MIBG (iodine-123 meta-iodobenzylguanidine) and CT imaging of the chest, abdomen, and pelvis is used in specific workup of children presenting with opsoclonus-myoclonus-ataxia syndrome, for diagnosing underlying neuroblastoma or ganglioneuroblastoma, they may not typically be the first line of imaging. It should be noted that opsoclonus-myoclonus-ataxia syndrome is one of the less common presentations of tumors such as neuroblastoma or ganglioneuroblastoma. A complete description of signs and symptoms of neuroblastoma or ganglioneuroblastoma and their workup are beyond the scope of this document.


Ataxia Child

Ataxia-Child

Ataxia Child. Ataxia-Child


Ataxia Child

Ataxia Child. Cerebellar stroke is a rare cause of acute ataxia in children, with one series identifying 3 cases out of 364 children presenting to the emergency department with acute ataxia [26]. Despite its rarity, diagnosing acute cerebellar infarct is critical because of implications for appropriate diagnostic workup and management.


Ataxia Child

Ataxia Child. Collective assessment of several studies suggests that, although acute imaging may reveal a clinically urgent condition [1,7,21,22,25-27], the yield of clinically significant findings may be highest in children >3 years of age with symptoms for >3 days duration and in the presence of extracerebellar symptoms, such as somnolence, encephalopathy, focal motor weakness, or cranial nerve involvement [13,18,20,26]. In young children presenting with acute cerebellar ataxia and a recent history of viral illness but without extracerebellar neurologic signs and symptoms and a negative urine drug screen, watchful waiting has been suggested [18], with imaging reserved for those with clinical deterioration. Therefore, the need for neuroimaging in the acute setting should be guided by the clinical presentation, history, and laboratory testing.


Ataxia Child

Ataxia Child. CT Head In a large study assessing imaging in 104 children presenting with acute or subacute ataxia, CT abnormalities were identified in up to 29% of children [20]. Clinically significant findings have been identified on CT in 7% of children presenting with acute ataxia [18]. Although the study by Whelan et al [13] only showed significant intracranial abnormalities on CT in 2.5% of the children presenting with acute ataxia, their study was limited by the fact that only a small proportion of children had imaging. In the absence of preceding trauma, CT is useful in identifying nontraumatic acute intracranial hemorrhage but can also identify hydrocephalus, cerebellar edema, and calcifications [7,28]. However, CT is less sensitive than MRI in displaying intracranial pathology including posterior fossa abnormalities [20,26]. There is no relevant literature to support the use of contrast-enhanced head CT in the evaluation of acute childhood ataxia.


Ataxia Child

Ataxia Child. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with acute ataxia and no history of recent trauma.


Ataxia Child

Ataxia Child. CTA Head and Neck CT angiography (CTA) of the head and neck may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26]. Although there is no relevant literature distinguishing between CTA of head and neck versus CTA of either the head or neck alone in these rare vascular causes of acute childhood ataxia, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone because the site of vascular abnormality may be in either the head or the neck or both locations.


Ataxia Child

Ataxia Child. CTA Head CTA of the head in conjunction with CTA of the neck may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or a vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26].


Ataxia Child

Ataxia Child. CTA Neck CTA of the neck, in conjunction with CTA of the head, may be helpful in children with ataxia due to a posterior circulation stroke, hemorrhage, or a vascular malformation. However, this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations are the etiology in only 1% to 3% of acute childhood ataxia [20,26].


Ataxia Child

Ataxia Child. CTV Head There is no relevant literature to support the use of CT venography (CTV) head in the initial evaluation of a child with acute ataxia and no history of recent trauma.


Ataxia Child

Ataxia Child. MRI Head In a study of 104 children imaged for acute or subacute ataxia, MRI abnormalities were identified in 64% of the cases [20]. However, clinically significant intracranial abnormalities on MRI have been reported in 14% of children presenting with acute or subacute ataxia [18,20]. MRI is more sensitive than CT in the evaluation of intracranial pathology in acute ataxia in children [20]. In a study by Luetje at al [20], abnormalities were identified on MRI but not on CT in 8 children. Intravenous (IV) contrast is helpful in infectious and postinfectious disorders, demyelinating conditions, and brain tumors, which are the common causes of acute cerebellar ataxia in children [19].


Ataxia Child

Ataxia Child. MRI Complete Spine MRI of the spine may be helpful in children with ataxia due to causes such as acute disseminated encephalomyelitis, brain tumors, and demyelinating disease, all of which may show additional abnormalities of the spinal cord [29]. Generally, if there is a high clinical suspicion for a condition that may have spinal cord or paravertebral abnormalities, MRI of the spine can be included when imaging the neuroaxis. Although there is no relevant literature discussing the specific use of contrast in MRI of the spine in acute childhood ataxia, addition of postcontrast imaging may be useful in assessing neoplastic, demyelinating, and inflammatory lesions, which are common causes of acute cerebellar ataxia in children [20].


Ataxia Child

Ataxia Child. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with acute ataxia and no history of recent trauma.


Ataxia Child

Ataxia Child. MRA Head and Neck MR angiography (MRA) of the head and neck may be a helpful tool in assessing ataxia due to a posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26]. Although there is no relevant literature distinguishing between MRA of head and neck versus MRA of either the head or MRA neck alone in these rare vascular causes of acute childhood ataxia, MRA of the head and neck may be more beneficial than either MRA head or neck alone because the site of vascular abnormality may be in either the head or neck or both locations.


Ataxia Child

Ataxia Child. MRA Head MRA of the head in conjunction with MRA of the neck may be a helpful tool in assessing ataxia due to posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26].


Ataxia Child

Ataxia Child. MRA Neck MRA of the neck in conjunction with MRA of the head may be a helpful tool in assessing ataxia due to posterior circulation stroke, hemorrhage, or vascular malformation. However, a posterior circulation stroke is rare in children, and this investigation may need to be decided based on the clinical presentation and concern for acute cerebellar infarct [7]. Stroke or vascular malformations may present with ataxia in 1% to 3% of cases [20,26].


Ataxia Child

Ataxia Child. MRV Head and Neck There is no relevant literature to support the use of MR venography (MRV) head and neck in the initial evaluation of a child with acute ataxia and no history of recent trauma.


Ataxia Child

Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with acute ataxia and no history of recent trauma.


Ataxia Child

Ataxia Child. MIBG Scan In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome, an MIBG scan may be helpful in the workup for identifying neuroblastoma, ganglioneuroblastoma, or ganglioneuroma as the causative etiology [2,13]. In the absence of any relevant literature, an MIBG scan may not be beneficial as a first-line imaging test in a child presenting with acute ataxia.


Ataxia Child

Ataxia Child. CT Chest, Abdomen, and Pelvis In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome with concern for neuroblastoma or ganglioneuroblastoma or ganglioneuroma, initial imaging with CT of the chest, abdomen, and pelvis with IV contrast may be helpful for diagnosis, although the clinical utility of CT as an initial imaging modality is less clear [2,13].


Ataxia Child

Ataxia Child. MRI Chest, Abdomen, and Pelvis In a child presenting with acute opsoclonus-myoclonus-ataxia syndrome, with clinical suspicion for neuroblastoma, ganglioneuroblastoma, or ganglioneuroma, MRI of the chest, abdomen, and pelvis without and with IV contrast may be helpful to identify the underlying mass [2,13]; however, there is no literature to support the use of this modality as an initial procedure.


Ataxia Child

Ataxia Child. Variant 2: Child. Acute ataxia, history of recent trauma. Initial imaging. Head trauma is a rare but important cause of ataxia in children, accounting for approximately 5% of acute childhood ataxias [18]. Ataxia after recent head and neck trauma may be due to intracranial hemorrhage, cerebral contusion, concussion, or traumatic vertebral dissection [18,30].


Ataxia Child

Ataxia Child. CTA Head and Neck CTA head and neck may be useful in the diagnostic workup of a child presenting with acute ataxia with a recent history of trauma, because of a vertebral artery dissection that may result in a cerebellar stroke and present with ataxia. Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury.


Ataxia Child

Ataxia Child. CTA Head CTA head in conjunction with CTA of the neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as vertebral artery dissection that may result in a cerebellar stroke and ataxia.


Ataxia Child

Ataxia-Child

Ataxia Child. Ataxia-Child


Ataxia Child

Ataxia Child. Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury.


Ataxia Child

Ataxia Child. CTA Neck CTA neck in conjunction with CTA of the head may be useful in the diagnostic workup if there is suspicion of cervical trauma resulting in cervical vascular injury such as vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, CTA of the head and neck may be more beneficial than either CTA head or CTA neck alone to assess entire extent of vascular injury.


Ataxia Child

Ataxia Child. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with acute ataxia following recent trauma.


Ataxia Child

Ataxia Child. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy of the head in the initial evaluation of a child with acute ataxia following recent trauma.


Ataxia Child

Ataxia Child. MRA Head and Neck MRA head and neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury.


Ataxia Child

Ataxia Child. MRA Head MRA head in conjunction with MRA of the neck may be useful in the diagnostic workup if there is suspicion of traumatic vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury.


Ataxia Child

Ataxia Child. MRA Neck MRA neck may be useful in the diagnostic workup if there is suspicion of traumatic cervical vascular injury such as a vertebral artery dissection that may result in a cerebellar stroke and ataxia. Although most vertebral artery dissections are extracranial in location, MRA of the head and neck may be more beneficial than either MRA head or MRA neck alone to assess entire extent of vascular injury.


Ataxia Child

Ataxia Child. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with acute ataxia following recent trauma.


Ataxia Child

Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with acute ataxia following recent trauma.


Ataxia Child

Ataxia Child. intermittent ataxia [34]. Recurrent ataxia in a child may be a manifestation of basilar migraines, benign paroxysmal vertigo, genetic disorders such as autosomal dominant episodic ataxia, and metabolic disorders [1,22,25,27,34,35]. Benign paroxysmal vertigo is typically diagnosed by history, physical examination, and when vestibular testing and neuroimaging are normal. Basilar migraines are typically diagnosed based on clinical symptoms and with normal neuroimaging. Autosomal dominant episodic ataxias are a clinically heterogeneous group (at least 6 types described), with imaging findings such as vermian atrophy described in type 2 episodic ataxia. Inborn errors of metabolism, such as intermittent maple syrup urine disease, pyruvate dehydrogenase deficiency, and Hartnup disease can also present with intermittent ataxia during times of stress or illness [1,36,37]; imaging in these cases may be helpful in identifying and characterizing the underlying neurometabolic disease. Children with rotational occlusion of the vertebral artery, also known as bow hunter syndrome, may present with episodic neurologic symptoms including ataxia [38]; however, this condition is rare enough that it is not a diagnostic target for initial evaluation for a child presenting with recurrent ataxia and interval normal neurology examination.


Ataxia Child

Ataxia Child. CT Head There is no relevant literature to support the use of head CT in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. MRI Head Although there is inadequate literature regarding the utility of MRI in intermittent or episodic ataxia in childhood, head MRI can be useful in diagnosing metabolic disorders and genetic abnormalities [1,25,34]. Neuroimaging in patients with basilar migraine and childhood benign paroxysmal ataxia is typically normal, and establishing normal neuroimaging supports the diagnosis of these conditions in the appropriate clinical setting [1,25,34]. In these aforementioned causes, there is not enough evidence in the literature to support the use of contrast-enhanced MRI in the initial evaluation of a child with episodic or intermittent ataxia [1,25,34].


Ataxia Child

Ataxia Child. MRI Complete Spine There is no relevant literature to support the use of MRI complete spine in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. MR Spectroscopy Head Some episodic ataxias may be due to underlying metabolic disorders, and in specific conditions in which an underlying metabolic disorder is suspected, MR spectroscopy may be useful in investigation.


Ataxia Child

Ataxia Child. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia-Child

Ataxia Child. Ataxia-Child


Ataxia Child

Ataxia Child. MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with episodic or intermittent ataxia.


Ataxia Child

Ataxia Child. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with recurrent ataxia.


Ataxia Child

Ataxia Child. Variant 4: Child. Chronic progressive ataxia. Initial imaging. Chronic progressive ataxia is a frequent presentation of ataxia in children. Signs and symptoms are typically of >2 months duration, but occasionally only a few weeks of symptoms may be present [5,14,34]. Cerebellar tumors, brain stem gliomas, and inflammatory disorders are collectively a common cause of chronic progressive ataxia in childhood [1,4,5,25]. Less commonly, inherited ataxias cause chronic progressive ataxias in children [1,4,5,25]. Inherited ataxias are a heterogenous group of clinically and genetically distinguished neurodegenerative disorders, which include autosomal dominant cerebellar ataxias, such as spinocerebellar ataxias, and autosomal recessive cerebellar ataxias, such as Friedreich ataxia.


Ataxia Child

Ataxia Child. Imaging plays an important role in children with chronic progressive ataxias. Brain imaging is crucial in the assessment of children with suspected brain tumors. In children with inherited chronic progressive ataxias, certain imaging findings can be helpful in the diagnostic workup [1,4,11,28,39-47]. Several hereditary cerebellar ataxias disorders have a progressive clinical course and varying progression of cerebellar hemispheric and vermian volume loss. In addition to cerebellar and vermian atrophy, associated signal abnormality and atrophy of the spinal cord and additional areas of the brain may be seen in certain conditions. Initial imaging provides a baseline for assessment of these abnormalities. Because of the phenotypic heterogeneity and the progressive nature of hereditary cerebellar ataxias, imaging in early childhood may be normal or subtly abnormal with imaging abnormalities becoming more apparent on follow up [14,46,48].


Ataxia Child

Ataxia Child. CT Head Few studies describe the utility of CT in identifying intracranial calcifications in specific conditions such as Cockayne syndrome, which can present with chronic progressive ataxia in children [14,28]. Although CT may identify major structural abnormalities or intracranial mass lesions, MRI is more sensitive for this purpose.


Ataxia Child

Ataxia Child. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. MRI Head MRI of the head is useful in the clinical workup of children with chronic progressive ataxia and can identify brain tumors and hereditary neurodegenerative disorders [1,4,11,28,39-47]. In a study of 82 patients with spinocerebellar ataxia type 1, 3, or 6, and 32 normal controls, Schulz et al [46] identified significant atrophy of the brainstem,


Ataxia Child

Ataxia Child. cerebellar vermis, and cerebellar hemispheres in affected children. Contrast-enhanced MRI of the head is useful in characterization of brain tumors that are a common cause of chronic progressive ataxia in children [1,4,5,25].


Ataxia Child

Ataxia Child. MRI Complete Spine MRI of the spine may be helpful in children with chronic progressive ataxia due to certain causes, such as central nervous system tumors and spinocerebellar ataxias. Postcontrast imaging may be required depending on case specifics, such as in the setting of central nervous system tumors to identify spinal metastatic disease.


Ataxia Child

Ataxia Child. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with chronic progressive ataxia. Altered metabolite ratios or presence of specific metabolites on MR spectroscopy may be useful in distinguishing posterior fossa tumor types and molecular subtypes.


Ataxia Child

Ataxia Child. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with chronic progressive ataxia.


Ataxia Child

Ataxia Child. Variant 5: Child. Chronic nonprogressive ataxia. Initial imaging. Chronic nonprogressive ataxias are comprised of a heterogenous group of cerebellar ataxias with early onset of cerebellar symptoms and no clinical change in severity during follow-up [1,4,25]. Commonly, symptom onset in these cases is within the first year of life, and this group of ataxias are referred to as chronic nonprogressive congenital ataxia [49]. Chronic nonprogressive ataxia in children may be due to syndromic, nonsyndromic, genetic, and acquired etiologies. In some syndromic causes such as Joubert syndrome and related disorders, ataxia is characteristic [50]. There are genetic causes of nonprogressive congenital ataxia with autosomal dominant, autosomal recessive, and x-linked inheritance patterns but with poor correlation between genotype and phenotype defined by imaging and clinical status [49]. Mutations in the Reelin signaling pathway are one of the autosomal recessive nonprogressive congenital ataxias with marked cerebellar and vermian hypoplasia and gyral simplification [4]. Developmental causes of nonprogressive congenital ataxia include posterior fossa malformations, such as rhombencephalosynapsis, Dandy-Walker syndrome, and Chiari II malformations [4]. Acquired causes of nonprogressive congenital ataxia include prenatally acquired cerebellar injury such as congenital cytomegalovirus infection, in utero cerebellar stroke, and perinatal disrupted development of the cerebellum as can be seen in premature infants and those with perinatal ischemic injury [51].


Ataxia Child

Ataxia Child. In the setting of chronic nonprogressive ataxia, imaging can be helpful in identifying the presence of congenital cerebellar, vermian, brainstem, and supratentorial brain malformations and acquired cerebellar disruptions due to prenatal or perinatal insult, although imaging can be normal in genetic etiologies [1,4,25,40].


Ataxia Child

Ataxia Child. CT Head Although CT may provide an assessment of major structural abnormalities in the posterior fossa, CT is less sensitive than MRI for assessment of intracranial structures [14,28]. The use of IV contrast is generally not warranted in assessment of brain structural abnormalities that present with chronic nonprogressive ataxia in children.


Ataxia Child

Ataxia-Child

Ataxia Child. Ataxia-Child


Ataxia Child

Ataxia Child. CT Complete Spine There is no relevant literature to support the use of CT complete spine in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. CTA Head and Neck There is no relevant literature to support the use of CTA head and neck in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. CTA Head There is no relevant literature to support the use of CTA head in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. CTA Neck There is no relevant literature to support the use of CTA neck in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. CTV Head There is no relevant literature to support the use of CTV head in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. MRI Head MRI is the most widely utilized imaging method to evaluate chronic nonprogressive ataxia [4,32]. In a child with chronic nonprogressive ataxia, MRI is useful in identifying cerebellar and brainstem malformations to aid diagnosis. Imaging can be particularly useful in the diagnosis of certain syndromic causes of chronic nonprogressive ataxia such as rhombencephalosynapsis, Dandy-Walker or Joubert syndrome, and related disorders that have characteristic imaging findings [50]. Diffusion tensor imaging can facilitate assessment of white matter tract structure in congenital brainstem and cerebellar anomalies [4,6,43,52]. For example, absence of decussation of the superior cerebellar peduncles in Joubert syndrome and abnormal dorsal pontine transverse white matter bundles in pontine tegmental cap dysplasia are seen on diffusion tensor imaging [4]. There is no literature to support the use of IV contrast in this setting.


Ataxia Child

Ataxia Child. MRI Complete Spine Because some congenital brainstem and cerebellar anomalies that present with chronic nonprogressive ataxia are associated with spinal anomalies, MRI of the complete spine may be helpful in individual cases [44]. There is no literature to support the use of contrast-enhanced imaging of the spine in this scenario.


Ataxia Child

Ataxia Child. MR Spectroscopy Head There is no relevant literature to support the use of MR spectroscopy head in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. MRA Head and Neck There is no relevant literature to support the use of MRA head and neck in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. MRA Head There is no relevant literature to support the use of MRA head in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. MRA Neck There is no relevant literature to support the use of MRA neck in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. MRV Head and Neck There is no relevant literature to support the use of MRV head and neck in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia Child. MRV Head There is no relevant literature to support the use of MRV head in the initial evaluation of a child with chronic nonprogressive ataxia.


Ataxia Child

Ataxia 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.


Ataxia Child

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


Ataxia Child

Ataxia Child. 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 examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate


Postmenopausal Subacute or Chronic Pelvic Pain. Subacute or chronic pelvic pain is a broad clinical presentation common to a variety of gynecologic, urinary, gastrointestinal, and musculoskeletal disorders. There are specific ACR Appropriateness Criteria documents pertaining to many of these diagnoses, which are detailed in Appendix 1. In particular, we emphasize the importance of both vaginal bleeding and suspected adnexal mass in postmenopausal women because of the prevalence of endometrial and ovarian neoplasia in this age group. These clinical features, if present, should take precedence over the general complaint of pelvic pain in directing the management algorithm. Patients with acute pain, suspected pelvic floor dysfunction, or urinary complaints may be managed in accordance with the respective algorithms for those conditions. Imaging evaluation for suspected endometriosis is not considered here as endometriosis is estrogen dependent and usually regresses after menopause [3]. If a postmenopausal woman is experiencing pain from endometriosis, it is likely secondary to scarring or reactivation that is due to postmenopausal hormonal therapy. In cases of persistent endometriosis-related symptoms after menopause, readers are referred to ACR Appropriateness Criteria guidance for the premenopausal age group (see Appendix 1).


Postmenopausal Subacute or Chronic Pelvic Pain. Finally, like other types of chronic pain, pelvic pain is a complex process with incompletely mapped cognitive and neurologic contributors. As such, there is a growing body of literature regarding potential use of neurologic imaging in patients with chronic pelvic pain [4-7]. However, central nervous system functional imaging remains in the research domain for evaluation of chronic pelvic pain at this time, so we will not consider it formally among the discussed imaging procedures.


Postmenopausal Subacute or Chronic Pelvic Pain. When all of these aspects of subacute and chronic pelvic pain in postmenopausal women are excluded from direct consideration, a handful of clinically significant conditions remain. We group these according to location of clinical symptoms: pain localized to the deep or internal pelvis, with potential etiologies and associated conditions, including pelvic venous disorders (commonly termed pelvic congestion syndrome), intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis versus chronic pain localized to the perineum, vulva, or vagina that arises from suspected vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain.


Postmenopausal Subacute or Chronic Pelvic Pain. Special Imaging Considerations When there is suspected local pathology in the vulva, perineum, or vaginal wall, translabial/transperineal ultrasound (US) or side-firing transvaginal probes may provide better visualization than end-firing transvaginal


Postmenopausal Subacute or Chronic Pelvic 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.


Postmenopausal Subacute or Chronic Pelvic Pain. Reprint requests to: publications@acr.org


Postmenopausal Subacute or Chronic Pelvic Pain. Postmenopausal Subacute or Chronic Pelvic Pain US probes [8]. There is scant evidence for imaging recommendations at this level of specificity, and it is assumed that the performing sonographer and sonologist will make appropriate technical adjustments to optimize imaging in these relatively uncommon clinical scenarios.


Postmenopausal Subacute or Chronic Pelvic Pain. Discussion of Procedures by Variant Variant 1: Postmenopausal subacute or chronic pelvic pain, localized to the deep pelvis. Initial imaging. Radiography Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of radiography to evaluate postmenopausal subacute or chronic pelvic pain localized to the deep pelvis.


Postmenopausal Subacute or Chronic Pelvic Pain. US Pelvis Transvaginal Pelvic US using a combined transabdominal and transvaginal approach is the initial imaging study of choice to evaluate postmenopausal subacute or chronic pelvic pain localized to the deep pelvis [9-12]. US can provide anatomic information about uterine size and endometrial canal distension, fallopian tube dilation, ovaries, and adnexal masses. Regarding the sequencing of examinations, several authors have pointed out that if the etiology of pelvic pain remains obscure after CT, a subsequent US has the capacity to provide additional information about the adnexa in particular [13,14]. US is broadly used and clinically accepted worldwide. However, high-quality evidence, such as clinical trials supporting specific usefulness of US, is lacking.


Postmenopausal Subacute or Chronic Pelvic Pain. Chronic pelvic inflammatory disease may be associated with pelvic fluid, hydrosalpinx or pyosalpinx, inflammatory adnexal masses, and peritoneal inclusions visible by US [15]. When pelvic adhesions are suspected, real-time dynamic US or cine clips may document abnormal adherence or lack of mobility of structures, particularly transvaginally. However, adhesive disease is a notoriously difficult diagnosis to confirm nonoperatively [16], and the evidence basis is anecdotal [15,17]. Furthermore, the causal linkage between adhesive disease and chronic pelvic pain remains unclear.


Postmenopausal Subacute or Chronic Pelvic Pain. Many women with pelvic venous disorders have morphologic findings of polycystic ovarian syndrome (enlarged ovaries with exaggerated central stroma and multiple small peripherally located follicles), but the associated clinical features of hirsutism and amenorrhea are rare [11,18]. Multiple investigators have identified a component of estrogen overstimulation in pelvic venous disorders, and symptoms may subside after menopause in some women [15]. There is a lack of clear definition and high-quality evidence in the clinical domain of pelvic venous disorders.


Postmenopausal Subacute or Chronic Pelvic Pain. CT Abdomen and Pelvis When pelvic venous disorders are clinically suspected, contrast-enhanced CT of the abdomen and pelvis may demonstrate engorged periuterine and periovarian veins, venous anatomic variants, and occasional compression of the left renal vein resulting in asymmetric left-sided pelvic varicosities [10,19-22]. However, CT lacks the capacity of US or MR to provide dynamic flow information [18].


Postmenopausal Subacute or Chronic Pelvic Pain. CT Pelvis When pelvic venous disorders are clinically suspected, contrast-enhanced CT of the pelvis may demonstrate engorged periuterine and periovarian veins, although their drainage into the renal vein or cava will not be evaluated without CT coverage of the abdomen [10,19-22]. In chronic inflammatory disease, CT may demonstrate pelvic fluid, peritoneal thickening, hydrosalpinx or pyosalpinx, and tubo-ovarian abscess [23].


Postmenopausal Subacute or Chronic Pelvic Pain. MRI Pelvis MRI is widely regarded as the problem-solving imaging examination of choice for chronic pelvic pain, particularly when US findings are nondiagnostic or inconclusive [11,15,24]. When MRI is clinically indicated, the use of a gadolinium-based IV contrast agent is preferred. Please see the ACR Manual on Contrast Media for additional information [25].


Postmenopausal Subacute or Chronic Pelvic Pain. The diagnostic performance of MRI/MR angiography is comparable to conventional venography for identifying pelvic venous disorders [26,27]. The use of MRI for this indication is growing accordingly [28], necessitating standardized interpretation and reporting [29]. T2-weighted imaging has the capacity to demonstrate pelvic varices, but signal intensity varies with flow velocity. Vein conspicuity and flow directional assessment are superior using time-resolved postcontrast T1-weighted imaging, which can directly demonstrate ovarian vein reflux [10,30]. Noninvasive imaging with MRI has largely supplanted conventional venography for diagnostic purposes, but venography may still be performed in the context of intended intervention.


Postmenopausal Subacute or Chronic Pelvic Pain. In chronic pelvic inflammatory disease, MRI with T2-weighted imaging may demonstrate edema, fluid collections, and distension of endometrial canal or fallopian tubes [15]. When infection is long standing, distinguishing between inflammatory and neoplastic masses is particularly difficult. Postcontrast T1-weighted imaging and diffusion-weighted imaging are particularly important in this setting [23]. Adhesive disease may be directly evident at MRI as low-signal bands between structures on nonfat saturated T2-weighted imaging or inferred in the presence of peritoneal inclusion cysts [11,15].


Postmenopausal Subacute or Chronic Pelvic Pain. Variant 2: Postmenopausal subacute or chronic pelvic pain, clinically suspected pathologies in perineum, vulva, or vagina. Initial imaging. Physical examination is the foundation of clinical evaluation of suspected pathology in the perineum, vulva, or vagina. The evidence supporting the use of imaging procedures in this clinical context largely assumes that the physical examination is abnormal.


Postmenopausal Subacute or Chronic Pelvic Pain. Radiography Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of radiography to evaluate postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina.


Postmenopausal Subacute or Chronic Pelvic Pain. US Pelvis Transvaginal Physical examination is the basis of diagnosis for most conditions localized to the vulvar skin [31]. Perineal and vaginal cysts are subcutaneous but often palpable and are appropriately evaluated with either translabial or transvaginal US, or both [8]. As with pelvic pain localized to the deep pelvis, US is widely regarded as the initial imaging study of choice for pelvic pain localized to the perineum, vulva, or vagina, but there is little high-quality evidence specifically supporting its use.


Postmenopausal Subacute or Chronic Pelvic Pain. Postmenopausal Subacute or Chronic Pelvic Pain US Duplex Doppler Pelvis Color and spectral Doppler are routinely used in pelvic sonography to evaluate internal vascularity of pelvic observations and distinguish cysts from soft tissue. Although it is rated as a separate imaging procedure per ACR methodology, the expert panel considers Doppler imaging to be a standard component of pelvic sonography. Special considerations for women with chronic pelvic pain may include evaluation of uterine artery blood flow, with low-resistance waveforms having been described in women with chronic pelvic pain [12].


Postmenopausal Subacute or Chronic Pelvic Pain. CT Abdomen and Pelvis To our knowledge, there is currently no evidence to support the use of CT for primary evaluation of postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina.


Postmenopausal Subacute or Chronic Pelvic Pain. CT Pelvis To our knowledge, there is currently no evidence to support the use of CT for primary evaluation of postmenopausal subacute or chronic pelvic pain localized to the perineum, vulva, or vagina.


Postmenopausal Subacute or Chronic Pelvic Pain. MRI Pelvis When MRI is clinically indicated, the use of a gadolinium-based IV contrast agent is preferred. Please see the ACR Manual on Contrast Media for additional information [25].


Postmenopausal Subacute or Chronic Pelvic Pain. When a cyst or mass is identified by US in the perineum, vulva, or vagina, MRI provides additional anatomic detail and evaluation of any enhancing soft-tissue components that might favor infection or neoplasia [11,24,32,33]. MRI has an important role as a problem-solving examination for lesion characterization and surgical planning, but there is, to our knowledge, no direct evidence to support the use of MRI as the initial or primary imaging examination for evaluation of pelvic pain localized to the perineum, vulva, or vagina, particularly when the physical examination is normal. However, there is emerging evidence to support the first- line utility of MRI when endometriosis or fistulizing disease are suspected [34]; readers are again referred to specific ACR Appropriateness Criteria guidelines for these clinical scenarios (see Appendix 1).


Postmenopausal Subacute or Chronic Pelvic Pain. MRI also enables accurate depiction of pelvic floor muscular anatomy, integrity, and function [35,36]. Pelvic floor dysfunction is discussed in detail in a separate ACR Appropriateness Criteria document (see Appendix 1), but specific note is made here of the usefulness of MRI for assessment of muscular hypertonicity in chronic pelvic pain syndromes [37].


Postmenopausal Subacute or Chronic Pelvic Pain. Summary of Recommendations Variant 1: US pelvis transvaginal, US duplex Doppler pelvis, and US pelvis transabdominal are usually appropriate for the initial imaging of postmenopausal subacute or chronic pelvic pain localized to the deep pelvis. These procedures are complementary and should be performed together. Variant 2: US duplex Doppler pelvis, US pelvis transvaginal, and US pelvis transabdominal are usually appropriate for the initial imaging of postmenopausal subacute or chronic pelvic pain with clinically suspected pathologies in the perineum, vulva, or vagina. These procedures are complementary and should be performed together.


Postmenopausal Subacute or Chronic Pelvic Pain. Although there are references that report on studies with design limitations, 5 well-designed or good-quality studies provide good evidence.


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


Nontraumatic Aortic Disease

Nontraumatic Aortic Disease. Introduction/Background Nontraumatic aortic disease can be caused by a wide variety of disorders, including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative diseases. Such conditions include, but are not limited to, atherosclerosis, aortic dissection, intramural hematoma, penetrating aortic ulcer, aortic aneurysms of various etiologies (degenerative, mycotic, or vasculitis-related), aortic rupture, thrombosis, aortobronchial fistula, congenital disorders, and extrinsic compression from adjacent masses. Diagnostic imaging is essential to assess the anatomy and extent of morphological changes involving the aorta. Nontraumatic aortic diseases may affect the lumen, wall, or perivascular structures. When there is aortic branch vessel involvement, end organ perfusion may be compromised.


Nontraumatic Aortic Disease

Nontraumatic Aortic Disease. Often, aortic disorders involve both the thoracic and abdominal aortic segments, thus requiring imaging of both regions. The clinical symptoms of aortic diseases vary widely. For example, acute aortic syndrome presents acutely with chest pain and elevated blood pressure, whereas atherosclerosis may be asymptomatic and detected incidentally.


Nontraumatic Aortic Disease

Nontraumatic Aortic Disease. All elements are essential: 1) timing, 2) reconstructions/reformats, and 3) 3-D renderings. Standard CTs with contrast also include timing issues and reconstructions/reformats. Only in CTA, however, is 3-D rendering a required element. This corresponds to the definitions that the CMS has applied to the Current Procedural Terminology codes.


Nontraumatic Aortic Disease

Nontraumatic Aortic Disease. aUniversity of Alabama at Birmingham, Birmingham, Alabama. bPanel Chair, Massachusetts General Hospital, Boston, Massachusetts. cPanel Vice-Chair, Emory Healthcare, Atlanta, Georgia. dSt. Francis Hospital, Catholic Health Services of Long Island, Roslyn, New York; Society for Cardiovascular Magnetic Resonance. eTufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery. fKnight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography. gMassachusetts General Hospital, Boston, Massachusetts. hMayo Clinic, Rochester, Minnesota. iUniversity of Virginia, Charlottesville, Virginia. jLoyola University Medical Center, Maywood, Illinois. kThe Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; Nuclear cardiology expert. lMassachusetts General Hospital, Boston, Massachusetts. mUT Southwestern Medical Center, Dallas, Texas. nStanford University Medical Center, Stanford, California. oSpecialty Chair, Emory University Hospital, Atlanta, Georgia.