Neuroimaging clinics of North America
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Society is increasingly demanding proof that imaging has an impact on patient outcome and questioning its cost on the health care delivery system. Radiologists should provide the following three key components in their research publications: (1) the statistical power and confidence intervals of the results obtained; (2) the diagnostic performance of the tests, including sensitivity, specificity, and ROC curves; and (3) comprehensive decision analysis and cost-effectiveness analysis to determine the impact that imaging has on health outcome, cost, and quality of life. Strict adherence to these evidence-based medicine principles would help advance the field and provide the best health care for patients.
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Neuroimaging Clin. N. Am. · May 2003
ReviewImaging of adults with low back pain in the primary care setting.
The evidence for the diagnostic accuracy of the four main imaging modalities used in low back pain (plain radiographs, CT, MR imaging, radionuclide bone scans) is variable in quality and limits the ultimate conclusions regarding the effectiveness and cost-effectiveness of diagnostic strategies. In addition, the frequent finding of abnormalities in normal adults limits the specificity of all of these tests. Nevertheless, MR imaging is likely in most cases to offer the greatest sensitivity and specificity for systemic diseases, and its performance is superior to that of radiographs and comparable with CT and radionuclide bone scans for most conditions causing neurologic compromise.
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The imaging work-up of patients with acute neurologic deficits should begin with noncontrast CT to exclude intracerebral hemorrhage. Based on positive results from the NINDS t-PA trial, the overriding objectives of imaging in the selection of patients for t-PA treatment are the detection of hemorrhage and rapid evaluation (speed of imaging). ⋯ Clinical outcome data are lacking; therefore, the routine use of screening MR imaging before t-PA therapy is not supported. Rigorous validation and correlation to clinical outcomes will be required.
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Neuroimaging Clin. N. Am. · May 2003
ReviewAdults and children with headache: evidence-based diagnostic evaluation.
Headache represents one of the most common complaints in the outpatient and emergency room setting [1]. Most causes of headache are benign and do not require emergent imaging or intervention. The authors' review of the diagnostic tests does not offer absolute indications for neuroimaging because most of the evidence is based on studies that are not randomized controlled trials. ⋯ In high-risk patients, MR imaging is the test of choice whereas in low-risk patients, close clinical observation with periodic reassessment is the best strategy [44]. Clinical diagnosis will always play a key role in the evaluation of headache disorders; however, for the small subset of patients who present with headache secondary to an intracranial space-occupying lesion, bleeding, or SAH, making the diagnosis is crucial to decreasing morbidity and mortality. CT, MR imaging, and lumbar puncture play important roles in the assessment of headache disorders, but their future roles will continue to evolve as the technology becomes more sophisticated and robust, and physicians become more expert with their use [1].
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Neuroimaging Clin. N. Am. · May 2003
ReviewEvidence-based imaging evaluation of the cervical spine in trauma.
Despite the relatively low frequency of cervical spine fractures in trauma patients, tremendous resources are expended on the use of imaging to exclude fracture. Some level 2 evidence can direct the selection of subjects for imaging and optimization of the imaging strategy. A suggested algorithm for evidence-based cervical spine imaging is shown in Fig. 1. ⋯ For high-risk subjects, cost-effectiveness analysis suggests that CT is the preferred initial strategy. When compared with radiography, the higher short-term costs of CT are counter-balanced by the decreased need for further imaging in patients without injury and by the increased sensitivity for fracture. The high-risk cervical spine criteria used at the author's center seem to be valid for identifying appropriate patients for initial imaging with CT.