Headaches: An Evidence Based Imaging Approach

Jorge A Vidal, MDAdjunct Professor of RadiologyEdgar Colon Negron, MDDirector Diagnostic RadiologyUPR-RCM

Imaging Modalities

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Digital Substraction Angiography (DSA)

Positron Emission Tomography (PET)

Single Positron Emission Computed Tomography (SPECT)

Ultrasound (US)

Radiographs

Imaging Modalities

Computed Tomography (CT)

Magnetic Resonance Imaging (MRI)

Digital Substraction Angiography (DSA)

Positron Emission Tomography (PET)

Single Positron Emission Computed Tomography (SPECT)

Ultrasound (US)

Radiographs

CT

Benefits

Higher spatial resolution than MRI

Excellent at showing life-threatening pathology

Hemorrhage, Hydrocephalus

Space-occupying lesions

MDCT can do angiography

FAST!!!

LimitationsLower contrast-resolution than MRI

HIGH RADIATION DOSE

Costly $$, but lower than MRI

Subdural Hematoma

MRI

Benefits

Higher contrast resolution than CT

Excellent at showing anatomy and pathology

Hemorrhage, Hydrocephalus, Space occupying lesions

Infections, inflammatory processes

Physiologic information (Spectroscopy)

Usually last stop shop final answer

LimitationsLower spatial-resolution than CT

Costly $$$

Long imaging time

Aneurysms

MR Spectroscopy

MRI

Contraindications

Pacemakers and defibrillator devices

Loose metal fragments in the orbits

Relative contraindicationsMetal in body (depends if it is ferromagnetic)

Surgical implants

Most are MRI compatible depending of magnets field strength

DSA

Excellent modality for evaluation of the arterial and venous system

Can be diagnostic and therapeutic

High radiation dose

Invasive

Higher risks

Mostly relegated to therapeutic use today or for problem-solving

PET-CT and SPECT

Excellent modality for evaluation of the brain physiology

Brain death studies

Epilepsy studies

Cancer and other tumors

HIGH RADIATION DOSE

Ultrasound

Used mostly for vascular evaluation in patients with SAH

Monitoring of intracranial arterial velocities

Radiographs

There is NO appropriate reason for the use of skull films for the evaluation of headaches!

I have a headache!

Questions to ask the patient

How long?

How strong?

Is it similar to previous episodes?

Immune status or pre-existing medical conditions (i.e. HTN, Sickle cell anemia)

Pregnant?

History of cancer, rapid weight loss?

Neurological deficits or new symptoms?

Recent travel destinations?

Thunderclap Headache

Sudden, severe headache

Worst headache of my life

In some studies up to 47% had a Subarachnoid hemorrhage.

Subarachnoid Hemorrhage

Aneurysm

Severe Unilateral Headache

In young patients be alert for pain radiating to the neck

Neurological symptoms

Horner syndrome

Stroke-like symptoms

Be suspicious for carotid or vertebral artery dissection

CTA and MRA

Temporal Headache

Patients older than 55 years old

New-onset headache in temple region

Tender superficial temporal artery

Temporal arteritis

Steroids

Avoid blindness or brainstem strokes

Copyright 2007 by the American Roentgen Ray SocietyBley, T. A. et al. Am. J. Roentgenol. 2005;184:283-287Temporal Arteritis

Pregnant Patients

Must have caution with Radiation Dose

Assess for neurological symptoms

Hydrocephalus

Extra-axial Mass

Extra-axial Mass

Sellar Mass

Lymphoma

Lymphoma

Toxoplasmosis

Take Home Points

Screening patients with isolated, nontraumatic headache by means of CT or MRI is usually not warranted, but may depend on clinical circumstances.

These procedures may be more likely to be positive in certain at risk populations.

Take Home Points

Patients with suspected meningitis or pregnant patients may pose diagnostic challenges.

HIV+, cancer patients and other at risk populations

Should be screened when presenting with a new onset headache

Take Home Points

RADIATION SAFETY

Please remember that CT is a high-radiation modality

Children

Pregnant patients

Retina

References

American College of Radiology Appropriateness Criteria for Headache

www.acr.org/ac

MRI Safetywww.mrisafety.com

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