Anatomical Part |
Symptoms/Presentation |
Further Delineation |
Imaging Recommendation |
Head |
Headache |
Acute trauma - Altered LOC, neurologic status |
CT without contrast |
Head |
Headache |
Trauma - subacute or distant |
MRI without contrast |
Head |
Headache |
Chronic |
MRI without contrast preferred over CT |
Head |
Headache |
Acute headache; severe, less than 3 days duration |
CT head without contrast |
 |
Headache |
Headache; severe, more than 3 days duration |
MRI without contrast, MRA (Circle of Willis), CTA if history of pacemaker |
Head |
Diagnosed sub-arachnoid hemorrhage |
For confrimation of initial diagnosis |
Conventional Angiogram - Gold Standard |
Head |
Suspect intracranial hemorrhage |
Acute |
CT without contrast |
|
Diagnosed intracranial hemorrhage |
|
MRI with and without contrast |
Head/MRA |
Family history of aneurysm |
|
MRA (Circle of Willis), CTA if history of pacemaker |
Head |
CVA/Infarct |
Hyperacute or acute |
CT or MRI; CT or MRI perfusion if available |
Head |
CVA/Infarct |
Sub-acute or chronic |
MRI without contrast preferred over CT |
Head/Angio |
Signs of Vascular Occlusive disease |
Intracranial |
MRA, CTA or conventional angiography as clinically indicated |
Head/Angio |
Signs of Vascular Occlusive disease |
Extracranial |
Duplex Ultrasound or MRA |
Head |
Focal neurologic symptoms |
|
MRI with and without contrast |
Head |
Seizure |
|
MRI with and without contrast |
Head |
Intracranial mass |
|
MRI with contrast, consider spectroscopy |
Head |
Dementia or psychiatric history |
|
MRI without contrast |
Head |
Multiple Sclerosis type symptoms |
Initial evaluation |
MRI without contrast |
|
|
Follow up evaluation |
MRI with contrast |
Head |
Cranial Nerves dysfunction |
CN I |
MRI without contrast |
|
|
CN II |
MRI without contrast - consider MS |
|
|
CN III |
MRI without contrast - consider MRA Circle of Willis |
|
|
CN IV |
MRI without contrast - conside MRA Circle of Willis |
|
|
CN V |
MRI with contrast |
|
|
CN VI |
MRI without contrast - consider MRA Circle of Willis |
|
|
CN VII & VIII |
MRI with & without contrast - IAC protocol |
|
|
CN IX - XII |
MRI with contrast |
Pediatric Head |
Developmental delay, structural abnormality |
|
MRI without contrast (Schedule SJH if sedation) |
|
Hydrocephalus |
|
CT without contrast or MRI |
Pediatric Head |
Infection, Mass, Vascular Abnormality |
|
MRI with contrast (Schedule SJH if sedation) |
Head/pituitary |
Pituitary Mass, hormone dysfunction |
|
MRI with contrast |
Head/Neck |
CSF leak |
|
CT cisternography is standard - MRI cisternography may be considered |
Head/Neck |
Mass/infection |
Orbits, sinuses, neck |
CT with contrast |
|
|
Nasopharynx and tongue base |
MRI with contrast |
Orbits |
Diplopia, mass |
To evaluate intraorbital contents |
CT orbits with and without contrast, MRI alternative |
|
|
To evaluate intracranial contents |
MRI with and without contrast |
Thyroid |
Endocrine abnormality |
|
Nuclear Medicine exam |
|
Nodule/mass |
|
Nuclear Medicine/Ultrasound |
|
Mass |
Assessment of neck extension/mets |
CT with contrast |
Parathyroid |
Abnormal Ca++ levels |
|
Nuclear Medicine parathyroid scan |
Sinuses |
Paranasal sinus disease |
|
CT coronal without contrast |
|
Mass/infection |
|
CT with contrast |
Temporal Bone |
Hearing loss |
Conductive |
CT Temporal bone without contrast |
|
Hearing loss |
Sensory |
MRI with and without contrast |
C- Spine |
Trauma |
No neurologic deficit |
X-ray, CT without contrast |
|
|
Neurologic deficit |
X-rays, MRI, CT complimentary |
C- Spine |
Radiculopathy/myelopathy |
|
MRI without contrast |
C- Spine |
Chronic pain |
|
X-rays, MRI without contrast |
T- Spine |
Pain |
|
X-ray, MRI without contrast, Nuclear Medicine Bone scan |
T- spine |
Tumor/infection |
|
MRI without and with contrast |
Lumbar Spine |
Acute low back pain |
< 30 days no red flags |
None |
Lumbar Spine |
Acute low back pain |
< 30 days red flags |
|
|
|
1. Recent trauma or mild trauma Patient age >50 |
X-rays, MRI without contrast |
|
|
2. Unexplained wieght loss |
MRI without contrast |
|
|
3. Unexplained fever |
MRI with contrast |
|
|
4. Immunosuppression |
MRI without contrast |
|
|
5. History of cancer |
X-rays, MRI with and without contrast |
|
|
6. IV drug use |
X-rays, MRI with contrast |
|
|
7. Prolonged use of cortical steroids/osteoporosis |
X-rays first, MRI without contrast |
|
|
8. Patients age >70 |
X-ray first, MRI without contrast |
Lumbar Spine |
Chronic back pain |
|
X-ray first, MRI without contrast |
Lumbar Spine |
Post-Op Evaluation |
Post surgery < 7 years |
MRI with contrast |
|
Post-Op Evaluation |
Post surgery >7 years |
MRI without contrast |
Lumbar Spine |
Tumor/infection |
|
X-ray, MRI with contrast, Bone Scan |
Sacrum |
Pain, tumor, mass |
|
MRI |
Brachial Plexus |
Radiculopathy/ Pain |
Tumor/infection unlikely |
MRI without contrast |
Brachial Plexus |
Radiculopathy/ Pain |
Consideration of tumor or infection |
MRI with contrast |
|
|
|
|
Shoulder |
Chronic pain/weakness |
Patient age > 50 years |
X-ray, MRI without contrast, US may be considered |
|
Chronic pain/weakness |
Patients age < 50 years |
X-rays, MRI Arthrogram, US may be considered |
|
Shoulder instability/pain |
All patients regardless of age |
MRI with Contrast/Arthrogram |
Shoulder |
Pain |
Concern of infection/cancer |
MRI with IV Contrast |
Elbow |
Bone evaluation |
Trauma, loose bodies |
X-rays, CT without contrast |
|
|
Loose bodies |
X-rays, Consider CT arthrogram |
|
Soft tissue evaluation |
Pain |
X-rays, MRI without contrast |
|
Soft tissue evaluation |
Infection or mass |
X-rays, MRI with contrast |
Wrist |
bone evaluation |
Trauma |
X-rays, CT without contrast |
|
Soft tissue evaluation |
Pain |
X-rays, MRI without contrast |
|
Soft tissue evaluation |
Infection or mass |
X-rays, MRI with contrast |
|
Pain |
Carpal ligament tear |
X-rays, Wrist Arthrogram |
Hand |
|
Pain |
X-rays, MRI without contrast |
|
|
Infection/Mass |
X-rays, MRI with contrast |
Hip/Pelvis |
Pain |
Non-specific pain, possible AVN |
X-ray, MRI |
Hip |
Pain |
Question labral tear |
MR arthrogram |
Thigh |
Pain |
Question mass or infection |
MRI with contrast |
Knee |
Pain |
Trauma |
X-ray, MRI if otherwise not going to surgery or MR felt to alter presurgical Dx |
Knee |
Pain |
Non-trauma, chronic |
X-rays first; if DJD no further imaging otherwise consider MRI |
Ankle |
Trauma, pain |
|
X-ray (3 View), CT, MRI |
Ankle |
Pain |
Question mass or infection |
X-ray (3 View), MRI with contrast |
Foot |
Trauma, pain |
|
X-ray, CT, MRI |
Foot |
Pain |
Cancer or infection |
X-ray, MRI with contrast |
|
|
For osteomyelitis screen- if no trauma or surgery |
Nuc Med 3 phase bone scan complimentary |
Thorax* |
Chest pain |
Aortic aneurysm/dissection |
CT w/o&w/ preferred. MRI alternative |
|
Mediastinal/ chest wall mass |
|
CT w/ preferred, CT w/o, MRI alternative |
|
Lung mass |
|
CT w/ preferred, CT w/o alternative, PET |
Abdomen |
Right upper quadrant pain |
Suspected gallbladder disease |
US primary, nuclear medicine, MRCP |
Abdomen |
Question kidney stone |
Renal colic |
CT KUB |
Abdomen* |
Suspect infection, mass or vascular |
|
CT with contrast |
*In general, CT is preferred modality in the chest/abd. but MR has an important adjunctive role and is often a good alternative for patients with significant contrast allergy or renal failure. |
Abdomen/Adrenal glands |
Question mass |
|
adrenal CT without contrast, MRI |
Abdomen/Renal |
Known/suspected renal mass |
|
CT w/o&w/ contrast, MR alternative |
Abdomen/Renal |
Painless hematuria |
|
IVP |
Abdomen/Vascular |
Hypertension |
Possible renal artery stenosis |
MR angiography, CT angiography, captorpril renogram |
Pelvis** |
Suspected ovarian mass/disease |
Ovaries not seen at US |
MR adjunctive |
|
Enlarged uterus |
fibroid(s) versus adenomyosis on US |
MR can be specific for both |
|
Suspected adenomyosis |
nonspecific or negative US |
MR is sens. and spec. |
|
Know ovarian mass |
suspected teratoma/endometreosis |
MR can be specific for these |
|
Gyn cancer staging |
|
CT or MR (surgeon's preference) |
|
Prostate cancer staging |
|
CT or MR |
|
Suspected urethral diverticulum |
Female |
MR can detect some not seen at voiding cystogram |
** Ultrasound is the first line modality for Gyn. imaging. MR can have an important adjunctive role, often in consultation with a gynecologist to determine if MR results will affect surgical management. |
