A guide to imaging for common neurological problems

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c4113 (Published 16 August 2010)
Cite this as: BMJ 2010;341:c4113

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  1. Adam B Cohen, neurologist and fellow of neuroradiology1,
  2. Joshua P Klein, neurologist and fellow of neuroradiology1,
  3. Srinivasan Mukundan, neuroradiologist and section head of neuroradiology2
  1. 1Departments of Neurology and Radiology, Brigham and Women’s Hospital, Harvard Medical School, 45 Francis Street, Boston, MA 02115, USA
  2. 2Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School
  1. Correspondence to: A B Cohen abcohen{at}partners.org

    Summary points

    • A careful clinical history, physical examination, and referral to evidence based guidelines when ordering imaging will reduce unnecessary studies

    • Although head computed tomography is less expensive, faster, and more readily available, magnetic resonance imaging is better at assessing most neurological conditions

    • Head computed tomography is recommended when urgent decisions are needed but has a low yield in transient neurological episodes

    • When vascular lesions are suspected, as in transient ischaemic attack, computed tomography angiography or magnetic resonance angiography of the head and neck is indicated

    • Treat most patients with low back and neck pain only conservatively; reserve imaging for those with red flag features and those who fail conservative treatment and are candidates for surgical intervention

    • Practitioners may need to assess the need for further testing and possible interventions in patients with incidental findings seen on neurological imaging

    Patients with headache, transient neurological episodes, symptoms after minor head trauma, and neck and low back pain often present to general practitioners and emergency room physicians. The examining doctor may be uncertain whether neurological imaging is needed. In this article, we discuss indications for imaging and tests that would be most useful in these scenarios. Table 1 summarises our approach to this problem. Figure 1 provides a walk through of representative images from patients with headache or minor head trauma, showing normal and abnormal findings. Figure 2 shows various examples of abnormal imaging findings relevant to the clinical scenarios described here.

    Occasionally, imaging leads to the incidental discovery of a lesion of unknown importance. We will also discuss the management and interpretation of such findings.

    Fig 1 (A) In acute headache or minor head trauma, head computed tomography may be recommended. All images are oriented axially. A normal head computed tomography is shown. The brain structures are evaluated for symmetry …

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