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Clinical Indications for corresponding imaging modality

Clinical problem	First imaging choice	Second imaging choice	Comments
HEAD, NECK AND SPINE
Cauda Equina Syndrome	MRI spine without contrast	CT spine without contrast	CT only if MRI is contraindicated and has low yield
Cerebral aneurysm	MRA head without contrast	CTA head without/with contrast	For patients with suspected or family history of aneurysm or follow up to prior known diagnosis
Cerebrovascular accident	CT head without contrast	MRI head without contrast	CT is needed first to exclude intracerebral hemorrhage
Dementia-Movement Disorder	CT head without contrast	MRI head without contrast
Dysphagia	Barium Swallow	Modified barium swallow (with speech therapist) if aspiration suspected	CT neck with contrast if neck mass suspected
Head trauma	CT head without contrast	MRI head without contrast	MRI is indicated only if CT findings requires further imaging. Routine x-ray series (skull, sinuses, facial bones, etc.) has very low sensitivity for significant injury
Headache- intracranial infection/inflammation	MRI head without/with contrast	CT head without/with contrast
Headache-chronic	CT head without contrast	MRI head without contrast
Headache-worst headache, sudden onset	CT head without contrast	CTA head without/with contrast, MRA head without contrast	If subarachnoid hemorrhage is suspected, CSF sampling may be needed since head CT can occasionally be false negative
Hearing loss - temporal bone trauma	CT temporal bone without contrast
Hearing loss - sensorineural	MRI IAC without/with contrast	CT temporal bone without contrast	CT temporal bone 1st choice if hearing loss is not sensorineural type
Intracranial bleed	CT head without contrast	MRI head without contrast	MRI is indicated only if CT findings requires further imaging
Myelopathy- spinal infection or metastatic	MRI spine without/with contrast	CT spine with contrast	CT only if MRI is contraindicated
Myelopathy-traumatic	CT spine without contrast	MRI spine without contrast	MRI if CT is inconclusive or further imaging desired
Neck vascular injury	CTA neck without/with contrast		Conventional angiography may be needed for vascular injury
Pituitary lesion or neoplasm	MRI sella without/with contrast	CT sella without/with contrast	CT only if MRI is contraindicated and has low yield
Proptosis, ophtalmoplegia	MRI orbit without/with contrast	CT orbit/head with contrast	CT is first choice if trauma is present
Seizures-Epilepsy	CT head without contrast	MRI head without/with contrast	Baseline CT is to exclude urgent findings like bleed. MRI is needed to search for seizure cause
Sinusitis- acute or chronic	CT sinus without contrast	X-ray sinus series	Limited sinus CT only uses few skipped coronal images; CT sinus with contrast or MRI sinus without/with contrast if further imaging is needed
Spine-Cervical stenosis or spondylosis	MRI spine without contrast	CT spine without contrast or spine x-rays
Spine-Lumbar stenosis or spondylosis or sciatica	MRI spine without contrast	CT spine without contrast or spine x-rays	MRI with contrast if prior back surgery is performed
Spine injury- mild, no neurologic symptoms	X-ray Spine	CT Spine without contrast
Spine injury- moderate/severe or neurologic symptoms	CT spine without contrast	MRI spine without contrast	MRI if spinal ligamentous injury is suspected or CT is not helpful
Vertigo-Ataxia, no trauma	MRI head without contrast	CT head without contrast	MRI spine without contrast if spinal origin of ataxia is suspected
Vision loss- sudden or transient	MRA head/neck without/with contrast	CTA head/neck without/with contrast
CHEST
Acute respiratory Illness	X-ray chest	CT chest with contrast	CT is reserved for complicated or unresolved cases, such as unresolved pneumonia or other lung disease
Breast mass	Diagnostic mammogram+US breast, if age over 30	US breast, if age below 30
Chest pain- aortic dissection or injury	CTA chest+abdomen without/with contrast	MRA chest/abdomen without/with contrast	Baseline chest x-ray is needed. Trans-esophageal echo if imaging findings are inconclusive
Chest pain - pulmonary embolism	CTA chest without/with contrast	V/Q scan	Baseline chest x-ray is needed
Dyspnea or hemoptysis	X-ray chest	CT chest with contrast
Metastasis screening	CT chest with contrast	FDG PET	Start with baseline chest x-ray
Rib injury/fracture	X-ray chest+Rib series	CT chest without contrast	CT chest with contrast for complicated cases
Solitary pulmonary nodule	CT chest without contrast	FDG PET	IV contrast is often needed for CT to evaluate mediastinum

Clinical problem

First imaging choice

Second imaging choice

Comments

ABDOMEN

Abdominal trauma

CT abdomen/pelvis with

PO+IV contrast

CT abdomen/pelvis with IV

contrast only

Other tests (US, MRI, KUB, barium studies, etc.) depend on CT findings

Acute abdominal pain

CT abdomen/pelvis with

PO+IV contrast

Other tests (US, MRI, KUB, barium studies, etc.) depend on CT findings

Adnexal mass

US pelvis TA+TV

MRI Pelvis without/with contrast

Start with bHCG test when needed. CT abdomen with

PO+IV contrast if PID is suspected

Adrenal nodule-indeterminate

CT abdomen without/with IV

contrast

MRI abdomen without contrast

MRI first choice in younger patients given high CT

radiation dose

Flank pain/ renal stone protocol

CT abdomen/pelvis without

PO or IV contrast

KUB

KUB or US renal is preferred for uncomplicated subsequent symptoms given high CT radiation dose

Hematuria

CT urogram without/with IV

contrast

US renal

No PO contrast used for CT. KUB is third alternative

Jaundice

US Abdomen

CT abdomen with PO+IV contrast

MRI Abdomen without contrast ( MRCP) is third alternative

Liver mass

MRI Abdomen without/with contrast

CT abdomen without / with PO+IV

contrast

FDG PET and US Abdomen are third alternatives

Postmenopausal vaginal bleed

US pelvis TA+TV

MRI pelvis without/with contrast

Transvaginal (TV) US has higher yield and should be included in all cases unless contraindicated

Pulsatile abdominal mass

CTA Abdomen without/with contrast

US aorta

US has limited coverage and sensitivity. MRA abdomen without/with contrast is third alternative

Renal failure

US renal

MRA kidneys without/with IV

contrast

MAG3 nuclear medicine renal scan is third alternative

Renal mass-indeterminate

CT abdomen without/with IV

contrast + PO Contrast

MRI kidney without/with IV contrast

US renal is third alternative. MRI first choice in younger patients given high CT radiation dose

Scrotal pain

US scrotum

Other imaging tests depend on ultrasound findings

Urinary trauma

CT abdomen/pelvis with IV

contrast

US renal

No PO contrast. Request delayed scan to check for urinary extravasation

UTI/pyelonephritis

CT abdomen/pelvis with

PO+IV contrast

US renal

Correlation with urinalysis is needed since imaging may be negative in infection

PEDIATRIC

Fever without source

X-ray chest

Other tests (whole body bone scan, CT abdomen/pelvis with PO+IV contrast, etc.) depend on clinical findings

Head Trauma

CT head without contrast

MRI head without contrast

MRI is indicated only if CT findings requires further imaging. Routine x-ray series (skull, sinuses, facial bones, etc.) has very low sensitivity for significant injury

Hematuria

US Renal

KUB

CT abdomen/pelvis without IV or PO contrast (stone protocol) is third alternative

Hip dysplasia-6 months or older

X-ray hips

US Hip

US can be attempted between 6-12 months but has low sensitivity at this period

Hip dysplasia-newborn

US hip

X-ray hips

If positive clinical finding is present, wait 2 wks, if screening for dysplasia due to risk factors with normal exam, wait 4-6 wks after birth

Kidney-abdomen trauma

CT abdomen/pelvis with IV

contrast

KUB

Limping

X-ray hips/lower extremity

Bone scan or MRI, if x-rays are not helpful

Nonaccidental trauma

Skeletal survey

CT head without contrast or organ of interest (with IV contrast if chest/abdomen/pelvis)

Bone scan is third alternative. MRI head without contrast if CT head is abnormal

Pyloric stenosis

US Abdomen

UGI barium study

KUB is needed as baseline and to check for gastric distention

Seizures-Epilepsy

CT head without contrast

MRI head without/with contrast

Baseline CT is to exclude urgent findings like bleed. MRI

is needed to search for seizure cause

UTI

VCUG+ US renal

CT abdomen/pelvis with PO+IV

contrast

CT for complicated cases

Vomiting

X-ray abdomen

UGI barium study

Small bowel series are not very helpful in childhood

BONE

Bone tumor

X-ray

MRI without/with contrast

CT if MRI is inconclusive

Extremity (hip, knee, wrist, etc.) pain or injury

X-ray

MRI without contrast

CT if MRI is not feasible or inconclusive

Infection/Osteomyelitis

X-ray

MRI without/with contrast

CT with contrast and 3-phase bone scan are third alternatives

Metastatic bone disease

Whole body bone scan

Skeletal survey

Skeletal survey only for Myeloma

Soft tissue mass

MRI without/with contrast

CT without/with contrast

Start with x-rays. If chest or abdominal wall mass, CT is first choice

Stress/insufficiency fracture

X-ray

MRI without contrast

CT is third alternative if MRI is inconclusive

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Updated 7/22/2011

Indications.pdf