Neuroimaging Pearls For The

Primary Care Provider

Praveen Dayalu, MD
Clinical Associate Professor
Department of Neurology
University of Michigan
 Themes in this talk
• Neuroradiology is often misused
• Pre-test clinical assessment is critical
• Think about “treatable causes”
• Incidental findings are extremely common
• Age associated changes are extremely
common
• Radiologists lack clinical information before,
and feedback after, their reports
 Neuroimaging Modalities
• CT (x-ray, ionizing radiation, with or without
contrast)
• MRI (magnetic field and radio pulses, with or
without contrast)
• Ultrasound– rarely used
• PET and SPECT imaging (radioactive tracer)
 “Enhancement”
• Implies that contrast is visible
• Can be normal (e.g., blood vessels)
• Often pathologic– implies blood-brain barrier
breakdown
Pre-contrast.
Post-contrast. Lesion enhances.
 Case -1
• 22 year old woman had cyclic vomiting as a
child, and frequent headaches. Two CT’s and
an MRI in her teens were normal. Now she
has a new severe headache with a sparkling C-
shaped scotoma moving across her vision
• Exam
• Re-image? If so, which modality?
 Brain CT’s: low but measureable risk

• The lifetime excess risk for a head CT scan is

about 1 incident cancer (any) per 1000 head
CT scans for young children (<5 years)

• 1/2000 for exposure at age 15 years.

Mathews JD et al BMJ 2013; 346: f2360

Miglioretti, DL et al JAMA Pediatr. 2013;167(8):700-707.
 “Choosing Wisely”:
AHS on non-emergent neuroimaging

• Don't neuroimage patients with stable

headaches that meet criteria for migraine

• Don't CT for headache when MRI is available,

except in emergency settings. (This matters most
for young people)

Loder E et al, Headache 2013; 53: 1651-9

 Case -2
55 year old woman has chronic low back pain,
depression, HTN, smoking.

MRI read: “L4-5 disk bulge causing mild canal stenosis

with disk-osteophyte complex narrowing the left neural
foramen. Disk bulge at L5-S1 causing moderate canal
stenosis. Impression: Degenerative Disk Disease”

- What do you tell patient?

- What do you do?
A bulging disk… but that’s life
 Case -3
A 55 y/o dentist develops slurred speech, then difficulty
swallowing, then left arm weakness, then progressive
difficulty with walking. 7 months after onset he has a
passive personality with judgment problems, and exam
shows 35 lb weight loss with muscle wasting,
hyperreflexia, and severe weakness in all limbs except
his right arm.

• Neuroimage? If so, where and what modality?

 Case -3
• His MRI results are… (to be discussed)

• What did we learn about neuroimaging in this

major category of neurologic disease?
 Case -4

• A 79 year old woman has had 3 years of

walking slower, and has occasional difficulty
coming up with names of acquaintances or
celebrities.
Her brain MRI
 MRI brain report:

“ 1. Moderate enlargement of lateral ventricles.

Some sulcal widening is also present. Suspicious for
NPH.

2. Mild to moderate chronic small vessel ischemia in

periventricular white matter and basal ganglia.”

• What do you tell patient

• What do you do?
 Head and neck angiography
• Assess vessels (usually arteries) of neck and head

• CT, MR, or conventional

• Carotid duplex is ultrasound based, and limited

• Why would we do this?

 Reasons for head & neck angiography
• Stroke workup; for acute treatment (thrombolysis,
clot removal)

• Stroke workup for secondary prevention

• Evaluating for cerabral aneurysms

• Evaluate for other vascular problems

(malformations, inflammation)
 Case -5
• 82 y/o man with history of diabetes,
peripheral neuropathy, occasional fall, and
recent DVT/ PE has several days of confusion
and somnolence
• Meds: gabapentin, lisinopril, metformin,
warfarin
• Workup?
Subdural hematoma
 Emergent neuroimaging?
• You practice in a remote part of the UP. A
small local ER is debating whether to keep
emergent neuroradiology services open 24/7.
For which scenarios would you like emergent
neuroimaging? What modality would you
need?

• Discuss
DWI
Cord compression