Emergency Indications for MRI

[bustbones26]

I am currently rotating at a hospital where the radiologist can "block" a patient from having an MRI if they feel that it is not indictated. Needless to say, a few times, this has lead to disasterous results.

Therefore, I was now given the assignment of researching a list of emergency indications for an MRI? Anybody have any source of say, a good article somewhere on this topic. Right now, I am fruitless so any help would be appreciated.

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[flighterdoc]

I am currently rotating at a hospital where the radiologist can "block" a patient from having an MRI if they feel that it is not indictated. Needless to say, a few times, this has lead to disasterous results.

Therefore, I was now given the assignment of researching a list of emergency indications for an MRI? Anybody have any source of say, a good article somewhere on this topic. Right now, I am fruitless so any help would be appreciated.

A radiologist can deny a diagnostic procedure?

Does the radiologist assume responsibility for the treatment and outcome of the patient when he does?

Not to get into a rads/ER argument, but do the radiologists actually see and touch the patient before denying the procedure? Do they discuss it with the ordering physician?

 

[bustbones26]

My rotation is at a Army Medical center with residency programs in internal med, ortho, gen surg. From my experience with the internal medicine guys, when an intern or resident wants to order any study on their patients, they have to have approve the procedure with the radiologist first. I do not know for sure, but I believe this system is set up so that interns/residents who are inexperienced are not wasting money on useless imaging studies. I really am not sure if radiologist at this hospital are allowed to block orders from attending physicians with full board certification.

And yes, these radiologist have no choice but to accept responsibility if say an MRI should have been done, they blocked it, and the patient "$hits the bed"!

 

[MustafaMond]

One indication for emergent MRI is to diagnose an acute stroke.
Diffusion weighted MRI is the fastest way to diagnose stroke.
It shows up almost immediately.
A decision whether to thrombolyse needs to be made within 3 hours of symptoms. This decision can be made with more certainty if you can see the stroke.

Well, that's one indication I can thin of.

Another is for really bad infections of a limb, (gas gangrene, necrotizing fascitis)

Another is neurological emergencies. ?spinal cord compression from fracture, or MR Angio for r/o aneurysm

 

[Whisker Barrel Cortex]

MRI brain for stroke in places that have a stroke service and if the patient is presents very soon after stoke.

MRI spine if symptoms of cauda equina syndrome. Not chronic pain that has gotten worse. Not back pain with no neurologic symptoms. Only if there are symptoms of cauda equina.

As for soft tissue eval, it will not make a difference in care. If there is a fluid collection, ultrasound is the modality to evaluate. If no drainable fluid, MRI will only show inflammation of the soft tissues, which you already know is there. It cannot tell the difference between necrotizing fasciitis and inflammation/edeam.

Evaluation of hip fractures in elderly osteoporotic patients. If plain film is negative and suspicion is high, this is the study of choice.

I'm sure there are a few others. I'll post them if I come up with them.

 

[Danala55]

any residents here from nj?

 

[Voxel]

1) Neurologic Signs or Symptoms or Clinical Suspicion of Cauda Equina, Cord Compression, or Epidural Abscess/Discitis require a stat MRI of the spine. This is *especially* important in patients patients who have known cancer, known cancer with bony mets, or clinically suspected discitis/epidural abscess. It is disasterous to ignore, in these patients, symptoms of new onset back pain or worsening back pain but WITHOUT neurologic *signs* on physical exam at this time. The reason it is so important is that once neurologic signs are found then it usually too late to reverse these neurologic signs even if the proper treatment is given (ie steriods, radiation, emergent neurosurgery).

2) Acute Stroke. Althought one may argue that every patient should get an MRI, the clinical reality is that patients would miss their 3 hour window after persenting to the ER and getting worked up, because the patient first needs a head CT to exclude a hemorragic infarct or large infarct (which would be contraindications to TPA). Also, neurologists would argue is that stroke is a clinical diagnosis. If the head CT does not contraindicate TPA therapy and the person is in the 3 hour window it is probably best to give the TPA as soon as clinically feasible. The less time the brain is hypoxic/ischemia the better.

3) Acute hip fracture in the elderly patient in whom plain films are negative but the clinical suspicion of hip fracture is high and who are surgical candidates.

4) Possibly Trauma (ie high speed mva, fell off a high story building) with ? neurologic signs in whom there is not fx/dislocation of c/t/l spine who will/may need urgent but not emergent surgery for other issues such as general/trauma abd surgery or extremity surgery by ortho/plastics.

5) Soft tissue infections are NOT an indication for stat MRI. CT and/or Ultrasound can do a good job of telling if there is a drainable fluid collection/abscess vs inflammatory/infectious changes.

That is all I can think of at this time. I believe many other thingse can wait until the morning or the next day or be imaged with another modality. (Please, be reasonable).

 

[MustafaMond]

I'd like to add SVC syndrome in a renal patient.

 

[Santiago]

1)Cauda equina definitely
2)Stroke..def after CT....for all practical purposes in our inst,all cases of acute neurological symptoms,a negative CT head becomes an emergent MR indication.But usually it gets done after CT.
3)We are doing a trial study in acute trauma and stroke patients using only MR axial scans...and using dedicated sequences..cutting down the time requirements..results are equivocal till now.
4)In arterial dissections...but the newer CT's are again better.

 

[Voxel]

Stroke: In an ideal world, after presenting to the ED, 10 minutes after initial symptoms and being seen by em and/or neurology right away, then off to CT scanner, then if neg off to the MRI scanner with a special protocol designed for stroke to be completed within a 3 hour window. My feeling is that this is difficult to accomplish in many places due to demands on resources and the clinical reality. And most patients probably present atleast 2 hours (or later) after new onset of symptoms, it will be tough to finish the a standard stroke protocol MRI within the 3 hour window to give TPA.

SVC syndrome in renal failure--- is a good one but only if they are decomensating, but many people who present with svc syndrome are not acutely decompensating but have had a slow onset of symptoms for a week or so.

(in patients without renal failure...) CTA is a much better test for arterial dissection than MRA with 16 slice CT scanners and proper reconstruction software. I have seen 4 slice CTA which also does a decent job and is better than MRA. Not only are the images better with CTA, but the CTA is MUCH quicker to perform.

 

[Docxter]

In some centers, a CT is not initially done for stroke. Patients get a quick and dirty abbreviated MRI with some sort of T2 imaging, diffusion, and maybe some sort of MRA. Some add a Sag T1 or a GRE as well. Of course, in these situations, the patient has been evaluated by a real neurologist and hyperacute stroke is the leading diagnosis. It's not used by the ED wanting an MRI for delta MS in an alcohol intoxicated patient or in someone with "generalized weakness".