Headache/Migraine Management

[PinchandBurn]

Hi Guys

I'm an interventional Pain Physician. I get referrals for various pain procedures from neurologists for blocks,etc primarily for Headache/Migraine mgt.

Question I have is, why do you guys get MRV, MRA of the brain? Obviously I know why you get a MRA (to r/o tumors,etc). With a MRV are you guy trying to r/o a thrombosis of some sort? Why the MRA then as well?

Just curious,Thanks

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[danielmd06]

Yep, you are correct.

As headaches can potentially be dangerous, and can potentially have a fairly unremarkable exam, neurologists love radiological studies for their workup.

At any rate, the MRV is to rule out a venous/sinus thrombosis, the MRA is to check for aneurysm, AVM, AVF, tumor etc, and the MRI is for non-vascular, and more generalized pathology. Thus, the arterial imaging alone wouldn't always help if seeking out a disorder in the venous system. However, sometimes these patients have already had a CTH/CTA prior to an MR study, in which case one might be better served by simply ordering an MRI/V and leaving the MRA out of the equation.

 

[PinchandBurn]

Yep, you are correct.

As headaches can potentially be dangerous, and can potentially have a fairly unremarkable exam, neurologists love radiological studies for their workup.

At any rate, the MRV is to rule out a venous/sinus thrombosis, the MRA is to check for aneurysm, AVM, AVF, tumor etc, and the MRI is for non-vascular, and more generalized pathology. Thus, the arterial imaging alone wouldn't always help if seeking out a disorder in the venous system. However, sometimes these patients have already had a CTH/CTA prior to an MR study, in which case one might be better served by simply ordering an MRI/V and leaving the MRA out of the equation.

can one order the MRI/V in one setting w/o increasing cost? And/or can you just add the MRA into the mix as well?

 

[typhoonegator]

The acquisition is different for MRA/MRV, but if you do time-of-flight imaging, you can do both an MRA and an MRV at the same appointment because you don't use contrast.

If you want a gadolinium MRA, then you aren't going to be able to get a GAD-MRV at the same time, because you would need to double dose the contrast (just like with CTA/CTV, although I feel like half the CTAs I get are so bolus-mistimed that I end up with a pretty decent CTV).

 

[Head]

MRV of the head is most commonly ordered when we suspect venous sinus thrombosis. As it pertains to your specialty - this is seen in ~1/3-1/2 of patients with pseudotumor cerebri. Whenever we see a young woman of significant girth with headaches and suspect pseudotumor, we will order an MRV due to this high association and potential need for anticoagulation.

 

[danielmd06]

can one order the MRI/V in one setting w/o increasing cost? And/or can you just add the MRA into the mix as well?

Sorry for the delay in answering but I believe TN answered you question.

Anecdotally, in residency I used the TOF option for MRA/V, but the quality of the MRA was usually lacking when this happened.