Evidence-Based Imaging - part 5 doc

(42). Another study by Lee et al. (43) also confirmed better diagnostic per- formance of sinus CT compared with plain films in 33 pediatric patients with chronic sinusitis. In that report, sensitivity and specificity of sinus plain films were 74% and 76% for maxillary sinus disease, and 41% and 44% for ethmoid sinus disease, respectively. There is conflicting evidence whether CT scan correlates with patients’ clinical symptoms (44–46). Patients with severe clinical symptoms may not have substantial mucosal thickening on CT. Arango and Kountakis (47) reported, on the other hand, that higher clinical symptom scores were seen in patients with severe abnormality on CT, compared with patients with normal or minimum findings on CT, and that the differences between these two groups were statistically significant. The fact that patient symptom scores did not correlate with the extent of the disease on CT may not necessarily indicate poor accuracy of sinus CT. When sinus CT is normal for a patient with a clinical diagnosis of chronic sinusitis, it is uncertain whether sinus CT underestimates disease or the patient warrants other diagnoses. C. Imaging Findings of Chronic Sinusitis Sinus CT may show mucosal thickening in various degrees, from minimal mucosal thickening to severe opacification of the paranasal sinuses. Fre- quently, for various reasons, sinus CT shows no or only minimal mucosal abnormality. Those patients with persistent chronic sinusitis symptoms have taken antiinflammatory medication as well as nasal spray; thus the degree of mucosal inflammation is usually subtle. Some ear, nose, and throat (ENT) surgeons schedule CT scan 4 to 6 weeks after antibiotic treat- ment, in order to see fine bone detail, which is often obscured by mucosal disease. Alternatively, those patients may have some other disease mimic- king chronic sinusitis. At the other extreme, sinus CT may show severe opacification of all paranasal sinuses. Occasionally, bone thickening or scle- rosis of the affected sinus is seen, suggestive of chronic periosteal inflam- mation. Polypoid soft tissue masses seen within the nasal cavity along with complete sinus opacification is suggestive of sinonasal polyposis (Fig. 12.3), which is often associated with allergy or asthma. Chronic sinusitis is occasionally caused by fungi, such as aspergillosis or mucormycosis. There are three distinct categories of sinus fungal infec- tion, allergic fungal sinusitis, invasive fungal sinusitis, and fungal ball (also called sinus mycetoma). Allergic fungal sinusitis patients are usually young and immunocompetent. Males are more frequently affected than females. Chronic inspissated secretion may appear in a high attenuation central region separated from the sinus wall on noncontrast CT (Fig. 12.4) (48). The lesion involves multiple sinuses and is often bilateral. Bone destruction and expansion is frequent, mimicking tumor. Treatment is usually surgical debridement and antifungal medication. Invasive fungal sinusitis is seen in immunocompromised or diabetic patients. Acute inva- sive fungal sinusitis presents with a rapid clinical deterioration and has very poor prognosis. Imaging studies often show infiltrative soft tissue abnormalities with gross bone destruction. Mucormycosis is one of the most common organisms in this entity. Fungal ball is a chronic fungal infec- tion within the sinus, resulting in a well-defined expansile soft tissue mass with mottled foci of calcification. 224 Y. Anzai and W.E. Neighbor, Jr. Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 225 Figure 12.3. A coronal CT image shows severe opacification of all paranasal sinuses with soft tissue fullness within the nasal cavity, suspicious for sinonasal polyposis. Notice thick mucosal thickening of maxillary sinuses bilaterally. Sclerotic changes are also seen in the ethmoid septi, suggestive of chronic inflammation. Figure 12.4. Allergic fungal sinusitis. A noncontrast axial CT image shows high attenuation soft tissue fullness within the ethmoid and sphenoid sinuses bilaterally with expansile bone erosion along the left laminae papyracea. Although MRI is not a primary imaging study for the evaluation of sinusitis, signal characteristics of sinus secretions were evaluated in chronic sinusitis patients. Som et al. (49) reported MR signal intensity changes as a function of protein concentration of sinus secretions. Normal sinus secre- tions consist predominantly of water; thus it appears as low T1 and high T2 signal intensities. As the sinus secretions become more viscous, the T1 signal intensity increases and the T2 signal intensity slowly decreases. Fur- thermore, as sinus secretions become more desiccated and sludge-like, they appear as low intensity in both T1 and T2 signals (50), and may become signal void. Fungal sinusitis is also associated with signal void on MRI as paramagnetic substance deposition such as manganese is fairly commonly seen with fungal infection. IV. Chronic Sinusitis: What Is the Role of Imaging in Chronic Sinusitis? Does Imaging Change Treatment Decision Making? Summary of Evidence: The roles of sinus CT for chronic sinusitis patients are to support clinical diagnosis, to evaluate the extent of disease, and to provide detailed anatomy to assist treatment planning. The literature sug- gests that sinus CT findings do not always correlate with patients’ clinical symptoms. Whether patients with a normal CT but with persistent clinical symptoms should undergo surgery remains controversial. There is not enough evidence that sinus CT predicts clinical outcomes or that sinus CT affects treatment decisions. Evidence for the CEA of diagnosis and treat- ment of chronic sinusitis is lacking (insufficient evidence). Supporting Evidence A. The Role of Sinus Computed Tomography for Chronic Sinusitis Despite a lack of evidence and problems related to the diagnosis of chronic sinusitis by CT, it remains the imaging study of choice for patients with chronic sinusitis. One of the roles of sinus CT is to determine whether a patient is truly suffering from chronic sinusitis, as symptoms related to chronic sinusitis are often vague and nonspecific (i.e., headache or facial pain). Completely normal sinus CT performed when a patient is having symptoms without prior medical treatment should suggest other diagnoses. Sinus CT is also indicated for patients who do not respond to medical management and to evaluate any obstructive lesions such as a polyp, inverting papilloma, or sinonasal cancer or anatomic abnor- malities impairing mucociliary drainage of the sinus (insufficient evidence). Once diagnosis of chronic sinusitis is supported clinically and radi- ographically, an imaging evaluation for chronic sinusitis patients should include the extent of the disease. The distribution of sinus involvement may indicate a mucosal abnormality at the ostiomeatal complex. One should also look for potential complications associated with sinusitis, such as orbital cellulitis/abscess, mucocele or pyocele, epidural or brain abscess using a soft tissue window. 226 Y. Anzai and W.E. Neighbor, Jr. B. The Role of Sinus Computed Tomography Before and After Endoscopic Sinus Surgery Chronic sinusitis develops from persistent or recurrent sinus inflammation, resulting in impaired ciliary function of the mucosa. Functional endoscopic sinus surgery (FESS) has been developed to repair mucociliary drainage of the sinus (51,52). Once surgery is indicated, CT is essential for providing detailed sinus anatomy as well as the status of ostiomeatal complex prior to FESS (insufficient evidence). Careful attention to key anatomic structures of the ostiomeatal complex is needed. These include ethmoid infundibulum, uncinate process, perpendicular plate and basal lamella of the middle turbinate, ethmoid bulla, nasofrontal duct, sphenoethmoid recess, and fovea ethmoidalis. Although certain anatomic variations such as concha bullosa, paradoxical middle turbinate, and nasal septum deviation can narrow the ostiomeatal complex (53,54), whether or not these anatomical variations cause increased risk of developing chronic sinusitis is not known. Functional endoscopic sinus surgery has been reported, primarily in the surgical literature, to provide improved clinical outcomes for patients with chronic sinusitis (51,55,56). However, a study evaluating the methodologic quality of FESS investigations reports that most outcome studies of endo- scopic sinus surgery lack a control group (57); thus the efficacy of FESS has not been well established. Moreover, a substantial portion of patients who had endoscopic sinus surgery have recurrent symptoms and seek further medical care. Those patients may receive a second or third surgery and undergo additional CT scan prior to the additional surgery. Common CT findings following FESS include uncinectomy, partial middle turbinectomy, and bulla ethmoidectomy. The extensive middle and inferior turbinectomies are no longer recommended since it may cause dryness or crusting of the nasal cavity, as well as turbulent air flow within the nasal cavity, resulting in perception of difficulty in breathing through the nose. One needs to look for a residual uncinate process for a patient with persistent symptoms after sinus surgery. C. Computed Tomography Prediction of Clinical Outcome for Chronic Sinusitis The value of sinus CT for predicting the clinical outcome of patients with chronic sinusitis is highly controversial (limited evidence). Stewart et al. (58) reported that the severity of sinus CT findings was a strong predictor of improved clinical outcome in 57 patients. Patients with severe pretreat- ment CT abnormality showed significantly larger improvement and lower absolute levels of symptoms after treatment. Kennedy (52), on the other hand, reported a strong correlation between the extent of disease on CT and a poor surgical outcome in 120 patients with chronic sinusitis. Wang et al. (59) also reported that in 230 consecutive patients the extent of disease on sinus CT predicts clinical outcome of endoscopic sinus surgery for chronic sinusitis in that the extent of disease was a consistent predictor (p < 0.05) for bleeding, complication occurrence, medical resource utiliza- tion, subjective sinus-specific health status, and physicians’ objective eval- uation of surgical outcomes. Another study of endoscopic sinus surgery indicated that advanced staging of CT and a previous history of sinus surgery correlated with poor clinical outcome (60). Mantoni et al. (61), on the other hand, reported that severity of sinus CT abnormality after FESS does not correlate well with a clinical relief of patients’ symptoms. Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 227 D. Does Sinus Computed Tomography Affect Treatment Decision Making in Chronic Sinusitis? Chronic sinusitis is managed either medically or surgically. Because sinus CT has uncertain diagnostic accuracy and poor correlation with patients’ clinical symptoms for chronic sinusitis, some otolaryngologists advocate that a treatment decision should be based solely on clinical grounds (44,46). Surgery is indicated when the maximum medical treatment fails to resolve the patient’s symptoms. However, there is no consensus as to what repre- sents the maximum medical treatment. Moreover, the basis of treatment decisions, medical versus surgical, for patients with chronic sinusitis is not universally established. Whether or not a patient should be treated surgi- cally, despite normal sinus CT, remains controversial (62). It is an open question whether treatment decisions are purely based on physical exam- ination and clinical history alone, or if sinus CT alters the treatment deci- sions by ENT surgeons (limited evidence). We prospectively administered questionnaires to a surgeon specializing in endoscopic sinus surgery each time he saw a patient for suspected sinusitis (63). After obtaining a clinical history and physical examination, we first asked his treatment decision without a sinus CT, and then again after reviewing the sinus CT. The abstracted clinical information of 27 patients was presented to two other otolaryngologists, and the same ques- tionnaires were administered before and after reviewing the sinus CT. Sinus CT altered dichotomous treatment decisions (surgical versus non- surgical) by the surgeon in one third of patients (9/27) and there was a tendency to offer the surgical treatment after reviewing the sinus CT more than before. The agreement among surgeons with clinical history and physical examination alone was poor but was much improved after reviewing sinus CT. The results of this study indicate that sinus CT provides pivotal objective information that affects treatment decisions and improves the agreement of treatment plans among surgeons (limited evidence). E. Special Case: Cost-Effectiveness Analysis in Chronic Sinusitis There has been no CEA for chronic sinusitis from the U.S. or Europe. Only one recent study from Taiwan assessed cost utility analysis of endoscopic sinus surgery. It measured the cumulative cost of treating chronic sinusi- tis with FESS based on severity of disease. Utility assessment was per- formed with the six-item Chronic Sinusitis Survey. The study revealed an average cost-utility ratio of $70,221 and a high cost-utility ratio of $103,872 (after conversion to U.S. dollars at 1999 rates) for treatment of more severe sinusitis cases due to the high cost and the limited utility gain (64). Some patients were admitted for surgery with an average length of stay of 2.4 days (standard deviation 1.2). The cost structure in their study showed that 66% of the total cost was the operation fee. Endoscopic sinus surgery is pri- marily performed on an outpatient basis in the U.S. Evidence is lacking in this field, and future research is needed (insufficient evidence). Health care costs for patients with chronic sinusitis were investigated in health maintenance organizations (HMOs) in the state of Washington. This study found that adult patients with chronic sinusitis have more nonurgent outpatient visits and fill more prescriptions than adult patients without a history of chronic sinusitis, not including endoscopic sinus surgery. The 228 Y. Anzai and W.E. Neighbor, Jr. Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 229 Use clinical prediction rules or risk factors to differentiate bacterial and viral infection ABX treatment Decongestant or anti-allergy Rx if h/o allergy Good clinical response No imaging study Screening sinus CT Positive CT Change ABX Negative CT Consider other diagnoses Poor response Patients present with acute sinusitis symptoms Suspect bacterial sinusitis (high probability for ABS) Uncomplicate viral infection (intermediate to low probability) Good clinical response Good clinical response No imaging Poor clinical response Screening sinus CT Positive CT Negative CT No imaging ABX depends on clinical exam Poor response Change ABX Consider other diagnoses Figure 12.5. Decision tree for imaging evaluation and management of acute bacterial sinusitis (ABS). ABX, antibiotics; h/o, history of. marginal total cost was $206 and the overall direct cost in the U.S. in 1994 was estimated to have been $4.3 billion (65). Take-Home Figures Decision trees for imaging evaluation and management of acute and chronic sinusitis are shown in Figures 12.5 and 12.6. Suggested Imaging Protocol 1. Noncontrast screening sinus CT 5-mm-thick coronal images every 10mm 140KVP, 200MA Indications: sinusitis symptoms not responding to medical treatment Diagnosis of sinusitis is in doubt, rule out sinusitis Recent sinusitis, need to evaluate response to treatment 2. Noncontrast fine-cut maxillofacial CT 2.5mm thick helical 140KVP, 200MA Indications: patients with chronic or recurrent sinusitis symptoms, need to evaluate anatomical abnormality Patients with chronic sinusitis failed to respond to the maximal medical treatment; considering endoscopic sinus surgery 3. Axial fine-cut maxillofacial CT with coronal and sagittal reformat 0.625- to 1.25-mm helical scanning with coronal and sagittal reformat 140KVP, 175MA Indications: patients require imaging-guided monitoring for endoscopic sinus surgery for skull base lesions or complex sinus surgery Future Research • Randomized controlled trial of antibiotic for patients with mucosal thickening only on CT in order to determine if this group of patients benefits from antibiotic treatment for acute sinusitis. • Cost-effectiveness analysis based on more realistic model assumptions regarding types and durations of antibiotic treatment for acute sinusitis. • Randomized controlled trial of endoscopic sinus surgery compared with sham surgery in order to determine the efficacy of FESS for patients with chronic sinusitis. • Prospective outcome assessment for chronic sinusitis patients treated medically or surgically in order to determine if CT findings predict treat- ment response. Summary Acute sinusitis • Despite inaccurate clinical diagnosis of acute or chronic sinusitis, the initial treatment decision is based on clinical diagnosis. • For patients present with acute sinusitis symptoms, if clinical suspicion for acute bacterial sinusitis is high, patients should be treated with antibiotics. • If clinical suspicion for acute bacterial sinusitis is intermediate or low, decongestant and conservative management is appropriate. Imaging study is indicated when patients failed to respond to the initial treatment. 230 Y. Anzai and W.E. Neighbor, Jr. Patients with history of chronic sinusitis presented with sinusitis symptoms Treat with ABX and other medical management if applicable (i.e. allergy) Good clinical response No imaging Changes ABX or consider steroid treatment, if appropriate Poor clinical response Good clinical response No imaging Sinus CT Screening sinus CT (if diagnosis needs to be confirmed) Full sinus CT (if surgery is a consideration) Normal sinus CT Localized disease on CT Anatomic abnormality Severe diffuse disease on CT Search for underlying systemic disease If refractory to the maximum medical Rx, a patient desires, consider surgery ??? Controversial If CT correlates w symptoms consider surgery Poor clinical response Figure 12.6. Decision tree for evaluation and management of chronic sinusitis. Chronis sinusitis • For patients with clinical diagnosis of chronic sinusitis, imaging study is indicated when patients failed to respond to medical management, in order to determine if symptoms are related to sinusitis, or to evaluate strutural abnormalities. • Sinus CT provides objective information as to how diffuse or localized disease is, and if symptoms are related to sinusitis, assisting treatment decisions for patients with chronic sinusitis. References 1. Gwaltney JM Jr, Jones JG, Kennedy DW. Ann Otol Rhinol Laryngol Suppl 1995; 167:22–30. 2. Gwaltney JM Jr, Sydnor A Jr, Sande MA. Ann Otol Rhinol Laryngol Suppl 1981; 90:68–71. 3. Collins J. National Center for Health Statistics Advanced Data 1988;1155: 1981–1916. 4. Willett LR, Carson JL, Williams JW Jr. J Gen Intern Med 1994;9:38–45. 5. Ioannidis JP, Lau J. Pediatrics 2001;108:51–58. 6. Clement PA, Bluestone CD, Gordts F, et al. Int J Pediatr Otorhinolaryngol 1999; 49:S95–100. 7. Garbutt JM, Gellman EF, Littenberg B. Qual Life Res 1999;8:225–233. 8. Turner BW, Cail WS, Hendley JO, et al. J Allergy Clin Immunol 1992;90:474–478. 9. Lau J, DZ, Engles E, et al. Diagnosis and Treatment of Acute Bacterial Rhinos- inusitis. Rockville, MD: Agency for Health Care Policy and Research, 1999. 10. Newman LJ, Platts-Mills TA, Phillips CD, Hazen KC, Gross CW. JAMA 1994; 271:363–367. 11. Senior BA, Kennedy DW, Tanabodee J, Kroger H, Hassab M, Lanza DC. Oto- laryngol Head Neck Surg 1999;121:66–68. 12. Amar YG, Frenkiel S, Sobol SE. J Otolaryngol 2000;29:7–12. 13. April MM, Zinreich SJ, Baroody FM, Naclerio RM. Laryngoscope 1993;103: 985–990. 14. Yang C, Talbot JM, Hwang PH. Am J Rhinol 2001;15:121–125. 15. Anderhuber W, Walch C, Braun H. Laryngorhinootologie 1997;76:315–317. 16. Lancaster J, Belloso A, Wilson CA, McCormick M. J Laryngol Otol 2000;114:630–633. 17. Schweitzer VG. Laryngoscope 1986;96:206–210. 18. Del Borgo C, Del Forno A, Ottaviani F, Fantoni M. J Chemother 1997;9:83–88. 19. Godofsky EW, Zinreich J, Armstrong M, Leslie JM, Weikel CS. Am J Med 1992; 93:163–170. 20. Collins JG. Vital Health Stat 1997;10:1–89. 21. National Center for Health Statistics: Sinusitis. NCHS, Hyattsville, MD, 2002. 22. Kaliner MA, Osguthorpe JD, Fireman P, et al. Otolaryngol Head Neck Surg 1997; 116:S1–20. 23. Gliklich RE, Metson R. Otolaryngol Head Neck Surg 1995;113:104–109. 24. Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoffman JR, Sande MA. Ann Emerg Med 2001;37:703–710. 25. Gonzales R, Bartlett JG, Besser RE, et al. Ann Emerg Med 2001;37:690–697. 26. Low DE, Desrosiers M, McSherry J, et al. Can Med Assoc J 1997;156:S1–14. 27. Hudgins PA, Mukundan S. AJNR 1997;18:1850–1854. 28. Shapiro GG, Furukawa CT, Pierson WE, Gilbertson E, Bierman CW. J Allergy Clin Immunol 1986;77:59–64. 29. Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. N Engl J Med 1994;330:25–30. 30. Lindbaek M, Hjortdahl P, Johnsen UL. BMJ 1996;313:325–329. 31. Engels EA, Terrin N, Barza M, Lau J. J Clin Epidemiol 2000;53:852–862. Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 231 32. Varonen H, Makela M, Savolainen S, Laara E, Hilden J. J Clin Epidemiol 2000; 53:940–948. 33. Chen LC, Huang JL, Wang CR, Yeh KW, Lin SJ. Asian Pac J Allergy Immunol 1999;17:69–76. 34. Lindbaek M, Hjortdahl P, Johnsen UL. Fam Med 1996;28:183–188. 35. American Academy of Pediatrics. Pediatrics 2001;108:798–808. 36. Garbutt JM, Goldstein M, Gellman E, Shannon W, Littenberg B. Pediatrics 2001; 107:619–625. 37. Balk EM, Zucker DR, Engels EA, Wong JB, Williams JW Jr, Lau J. J Gen Intern Med 2001;16:701–711. 38. Benninger MS, Sedory Holzer SE, Lau J. Otolaryngol Head Neck Surg 2000; 122:1–7. 39. Fagnan LJ. Am Fam Physician 1998;58:1795–1802, 1805–1796. 40. Gonzalez Morales JE, Leal de Hernandez L, Gonzalez Spencer D. Usefulness of simple paranasal sinus radiographs and axial computed tomography in the diagnosis of chronic sinusitis (in Spanish). Rev Alerg Mex 1998;45:17–21. 41. Garcia DP, Corbett ML, Eberly SM, et al. J Allergy Clin Immunol 1994;94: 523–530. 42. Burke TF, Guertler AT, Timmons JH. Acad Emerg Med 1994;1:235–239. 43. Lee HS, Majima Y, Sakakura Y, Inagaki M, Sugiyama Y, Nakamoto S. Nippon Jibiinkoka Gakkai Kaiho 1991;94:1250–1256. 44. Stewart MG, Sicard MW, Piccirillo JF, Diaz-Marchan PJ. Am J Rhinol 1999; 13:161–167. 45. Piccirillo JF, Merritt MG Jr, Richards ML. Otolaryngol Head Neck Surg 2002; 126:41–47. 46. Bhattacharyya T, Piccirillo J, Wippold FJ. Arch Otolaryngol Head Neck Surg 1997;123:1189–1192. 47. Arango P, Kountakis SE. Laryngoscope 2001;111:1779–1782. 48. Mukherji SK, Figueroa RE, Ginsberg LE, et al. Radiology 1998;207:417–422. 49. Som P, Dillon W, Fullerton G, et al. Radiology 1989;172:515–520. 50. Som PM, Brandwein M. In: Som PM, Curtin HD, eds. Head and Neck Imaging, 3rd ed. St. Louis: Mosby, 1996;125–315. 51. Kennedy DW, Senior BA. Otolaryngol Clin North Am 1997;30:313–330. 52. Kennedy DW. Laryngoscope 1992;102:1–18. 53. Calhoun KH, Waggenspack GA, Simpson CB, Hokanson JA, Bailey BJ. Oto- laryngol Head Neck Surg 1991;104:480–483. 54. Yousem DM, Kennedy DW, Rosenberg S. J Otolaryngol 1991;20:419–424. 55. Senior BA, Kennedy DW, Tanabodee J, Kroger H, Hassab M, Lanza D. Laryn- goscope 1998;108:151–157. 56. Metson R, Gliklich RE. Arch Otolaryngol Head Neck Surg 1998;124:1090–1096. 57. Lieu JE, Piccirillo JF. Arch Otolaryngol Head Neck Surg 2003;129:1230–1235. 58. Stewart MG, Donovan DT, Parke RB, Bautista MH. Otolaryngol Head Neck Surg 2000;123:81–84. 59. Wang PC, Chu CC, Liang SC, Tai CJ. Otolaryngol Head Neck Surg 2002; 126:154–159. 60. Marks SC, Shamsa F. Am J Rhinol 1997;11:187–191. 61. Mantoni M, Larsen P, Hansen H, Tos M, Berner B, Orntoft S. Eur Radiol 1996;6:920–924. 62. Kennedy DW. JAMA 2000;283:2143–2150. 63. Anzai Y, Weymuller EA, Yueh B, Maronian N, Jarvik JG. The impact of sinus computed tomography on treatment decisions for chronic sinusitis. Arch Oto- laryngol Head Neck Surg 2004;130(4):423–428. 64. Wang PC, Chu CC, Liang SC, Tai CJ. Otolaryngol Head Neck Surg 2004; 130:31–38. 65. Murphy MP, Fishman P, Short SO, Sullivan SD, Yueh B, Weymuller EA Jr. Oto- laryngol Head Neck Surg 2002;127:367–376. 232 Y. Anzai and W.E. Neighbor, Jr. 13 Neuroimaging for Traumatic Brain Injury Karen A. Tong, Udo Oyoyo, Barbara A. Holshouser, and Stephen Ashwal I. Which patients with head injury should undergo imaging in the acute setting? II. What is the sensitivity and specificity of imaging for injury requir- ing immediate treatment/surgery? III. What is the sensitivity and specificity of imaging for all brain injuries? IV. Can imaging help predict outcome after traumatic brain injury (TBI)? A. Imaging classification schemes B. Normal scans C. Brain swelling D. Midline shift E. Hemorrhage F. Number/size/depth of lesions G. Diffuse axonal injury H. Combinations of imaging abnormalities and progressive brain injury I. Abnormalities of perfusion or activation J. Measures of atrophy K. Combinations of clinical and imaging findings V. Is the approach to imaging children with traumatic brain injury different from that for adults? 233 ᭿ Head injury is not a homogeneous phenomenon and has a complex clinical course. There are different mechanisms, varying severity, diversity of injuries, secondary injuries, and effects of age or under- lying disease. ᭿ Classifications of injury and outcomes are inconsistent. Differences in diagnostic procedures and practice patterns prevent direct compari- son of population-based studies. Issues Key Points [...]... Neuroimaging for Traumatic Brain Injury 255 B A NAA 14 14 12 12 Cre 10 10 Cho 8 8 Ins 6 6 Glx 4 4 2 2 0 0 –2 4.0 3 .5 3.0 2 .5 2.0 1 .5 4.0 1.0 3 .5 3.0 2 .5 2.0 1 .5 1.0 Occipital Gray Matter Normal Control Subject Occipital Gray Matter Severely Disabled Patient D C NAA 14 Cho 15 12 10 10 8 6 5 4 2 0 0 4.0 3 .5 3.0 2 .5 2.0 1 .5 Parietal White Matter Severely Disabled Patient 1.0 4.0 3 .5 3.0 2 .5 2.0 1 .5 1.0... Neuroradiol 2001;22:143– 151 54 Wild JM, Macmillan CS, Wardlaw JM, et al MAGMA 1999; 8:109–1 15 55 Garnett MR, Corkill RG, Blamire AM, et al J Neurotrauma 2001;18:231–240 56 Abdel-Dayem HM, Abu-Judeh H, Kumar M, et al Clin Nucl Med 1998;23:309–317 57 Stamatakis EA, Wilson JT, Hadley DM, Wyper DJ J Nucl Med 2002;43:476–483 58 Kant R, Smith-Seemiller L, Isaac G, Duffy J Brain Inj 1997;11:1 15 124 59 Bergsneider M,... Invest Radiol 19 95; 30 :50 2 50 6 49 Ricci R, Barbarella G, Musi P, Boldrini P, Trevisan C, Basaglia N Neuroradiology 1997;39:313–319 50 Ross BD, Ernst T, Kreis R, et al J Magn Reson Imaging 1998;8:829–840 257 258 K.A Tong et al 51 Garnett MR, Blamire AM, Rajagopalan B, et al Brain 2000;123:1403–1409 52 Cecil KM, Lenkinski RE, Meaney DF, McIntosh TK, Smith DH J Neurochem 1998;70:2038–2044 53 Sinson G, Bagley... Psychiatry 19 95; 59:328–331 76 Tomei G, Sganzerla E, Spagnoli D, et al J Neurosurg Sci 1991; 35: 61– 75 77 Cordobes F, Lobato RD, Rivas JJ, et al Acta Neurochir 1986;81:27– 35 78 Wang HD, Duan GS, Zhang J, Zhou DB Chin Med J 1998;111 :59 –62 79 Parizel PM, Ozsarlak O, Van Goethem JW, et al Eur Radiol 1998;8:960–9 65 80 Wallesch C-W, Curio N, Kutz S, Jost S, Bartels C, Synowitz H Brain Inj 2001; 15: 401–412 81... Bryan N, Denckla MB J Neurol Neurosurg Psychiatry 2001;70: 350 – 358 Blackman JA, Rice SA, Matsumoto JA, et al J Head Trauma Rehabil 2003;18:493 50 3 Tong K, Ashwal S, Holshouser BA, et al Ann Neurol 2004 ;56 :36 50 Levin HS, Benavidez DA, Verger-Maestre K, et al Neurology 2000 ;54 :647– 653 Ashwal S, Holshouser BA, Shu SK, et al Pediatr Neurol 2000;23:114–1 25 Brenner T, Freier MC, Holshouser BA, Burley T, Ashwal... and limitations of the different neuroimaging modalities • Case study 1: Example of MR imaging for TBI: This case study illustrates imaging findings of DAI in a 10-year-old boy struck by a car (Fig 13.1) • Study 2: Example of MR spectroscopy This case study illustrates the metabolite changes in single-voxel short echo time proton spectra (TE = 20 msec) from a 28-year-old man admitted to hospital with severe... improvements in medical care, use of evidence-based guidelines, and injury-prevention efforts (17) An estimated 5. 3 million U.S residents live with permanent TBI-related disabilities (17) Direct costs are estimated at $4 billion/year (16) In 19 95, total direct and indirect costs of TBI were estimated at $56 billion/year (17) There are few data on the costs of TBI related solely to imaging There has been one... (b) diffuse injury II (small Chapter 13 Neuroimaging for Traumatic Brain Injury lesions): cisterns are present, midline shift . Axial fine-cut maxillofacial CT with coronal and sagittal reformat 0.62 5- to 1. 2 5- mm helical scanning with coronal and sagittal reformat 140KVP, 175MA Indications: patients require imaging- guided. Fullerton G, et al. Radiology 1989;172 :51 5 52 0. 50 . Som PM, Brandwein M. In: Som PM, Curtin HD, eds. Head and Neck Imaging, 3rd ed. St. Louis: Mosby, 1996;1 25 3 15. 51 . Kennedy DW, Senior BA. Otolaryngol. 1991;20:419–424. 55 . Senior BA, Kennedy DW, Tanabodee J, Kroger H, Hassab M, Lanza D. Laryn- goscope 1998;108: 151 – 157 . 56 . Metson R, Gliklich RE. Arch Otolaryngol Head Neck Surg 1998;124:1090–1096. 57 . Lieu