Choosing Wisely in Headache Medicine: The American Headache Society's List of Five Things Physicians and Patients Should Question

In an effort to draw attention to tests and procedures associated with low‐value care in headache medicine, the American Headache Society (AHS) joined the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. The AHS president appointed an ad hoc “Choosing Wisely” task force of the AHS. The committee surveyed AHS members to develop a candidate list of items for the AHS “Top 5” list of low‐value care in headache medicine. Through a process of literature review and consensus, the final list of five items was chosen. Draft recommendations went through several rounds of revision and a process of outside review. The AHS Board of Directors approved the final list of “Five Things.” The five recommendations approved by the AHS Board of Directors are: (1) don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine; (2) don't perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings; (3) don't recommend surgical deactivation of migraine trigger points outside of a clinical trial; (4) don't prescribe opioid‐ or butalbital‐containing medications as a first‐line treatment for recurrent headache disorders; and (5) don't recommend prolonged or frequent use of over‐the‐counter pain medications for headache. We recommend that headache medicine specialists and other physicians who evaluate and treat headache disorders should use this list when discussing care with patients.     

The Thunderclap Headache: Approach and Management in the Emergency Department

BackgroundA thunderclap headache (TCH) is a severe headache reaching at least 7 (out of 10) in intensity within 1 min of onset, and can be the presenting symptom of several conditions with potential for significant morbidity and mortality.Objective of the ReviewThis narrative review evaluates the various conditions that may present with TCH and proposes a diagnostic algorithm for patients with TCH.DiscussionTCH is a symptom associated with several significant diseases. The most common diagnosed condition is subarachnoid hemorrhage (SAH). Other diagnoses include reversible cerebral vasoconstriction syndrome, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, spontaneous intracranial hypotension, and several others. Patients with TCH require history and physical examination, with a focus on the neurologic system, evaluating for these conditions, including SAH. Further testing often includes head computed tomography (CT) without contrast, CT angiography of the head and neck, and lumbar puncture. Evaluation must take into account history, examination, and the presence of any red flags or signs suggestive of a specific etiology. An algorithm is provided for guidance within this review incorporating these modalities. Management focuses on the specific diagnosis. If testing is negative for a serious condition and the patient improves, discharge home may be appropriate with follow-up.ConclusionsPatients presenting with TCH require diagnostic evaluation. History and examination are vital in assessing for risk factors for various conditions. Focused testing can assist with diagnosis, with management tailored to the specific diagnosis.     

增强CT与MRI诊断腰椎结核的临床价值对比

目的  比较增强CT和MRI诊断腰椎结核的应用价值。方法  选取2019年6月~2021年6月在本院收治疑似60例腰椎结核患者,均行增强CT和MRI图像,以病理或治疗随访结果为金标准,观察其影像学表现,比较两种方法对腰椎结核的诊断效能。结果  60例患者中,有42例确诊为腰椎结核。增强CT检出腰椎结核36例,与金标准比较,敏感度为85.71%,特异性为77.77%,准确度为83.33%,Kappa值为0.615;MRI检出腰椎结核40例,与金标准比较,敏感度为95.24%,特异性为88.89%,准确率为93.33%,Kappa值为0.841;MRI在椎间盘受累、椎旁脓肿、椎管受累中的检出率均高于增强CT（P<0.05）,CT在死骨形成中的检出率高于MRI（P<0.05）。结论  增强CT与MRI对诊断腰椎结核均具有一定的临床效能,MRI优于增强CT,MRI在椎间盘受累、椎旁脓肿、椎管受累的诊断有明显优势,增强CT在死骨形成检出率优于MRI。     

Lumbar Puncture First: An Alternative Model for the Investigation of Lone Acute Sudden Headache

Subarachnoid hemorrhage (SAH) is a diagnosis often considered in patients presenting to the ED with acute sudden headaches, but with normal physical examinations. Standard of care today is for these patients to be investigated by noncontrast CT scan followed by lumbar puncture (LP) for negative CTs. However, given that most investigated patients have benign headaches, most of the CT and LP results are normal. The authors studied, by means of a theoretical analysis, the impact of an alternative diagnostic model, in which LP would be the first (and, in most cases, only) diagnostic test for patients suspected of SAH who met lone acute sudden headache (LASH) criteria. Given reasonable assumptions, for every 100 patients investigated, the "LP-first" model would result in 79 to 83 fewer CT scans and only seven to 11 additional LPs, as compared with traditional strategies. Among ED headache patients meeting LASH criteria, the authors believe use of this model could result in more efficient use of resources, minimal additional morbidity, and equal diagnostic accuracy for SAH.     

听神经鞘瘤MRI与CT诊断价值的比较

本文对手术病理证实的23例听神经鞘瘤和4例有听力受损症状而影像学检查皆为阴性的“非听神经鞘瘤”的MRI及CT所见进行了分析和对比。在显示桥脑小脑角(CPA)区听神经鞘瘤的敏感性方面,MRI显著高于CT(0.01相似文献   

强直性脊柱炎骶髂关节病变的 CT 与 MRI 影像学诊断价值

目的：探讨 CT 和 MRI 对强直性脊柱炎骶髂关节病变的诊断价值。方法对80例强直性脊柱炎骶髂关节病变患者均采用螺旋 CT 和 MRI 影像检测诊断,比较两种诊断的影像表现和诊断结果。结果CT 影像 I 级诊断率为27.5%,显著低于 MRI 影像 I 级诊断率(42.5%),差异有显著性(χ2=3.96,P <0.05);影像0、II、III、IV 级诊断率与 MRI 诊断结果比较差异均无显著性(P >0.05)。结论CT 和 MRI 均为强直性脊柱炎骶髂关节病变的有效诊断方法,二者各有其特点和不足,但 MRI 更适合早期诊断。     

Impact of the International Headache Society criteria on the use of neuroimaging for headache diagnosis in a headache clinic

OBJECTIVE: To evaluate the impact of the introduction of the International Headache Society (IHS) criteria on the use of neuroimaging for headache diagnosis in a specialist outpatient center. BACKGROUND: The general indications for neuroimaging in headache are a matter of debate. International Headache Society criteria should improve diagnostic accuracy, consequently reducing the use of expensive diagnostic procedures such as brain CT or MRI scan. METHODS: We reviewed the medical records of all 2739 new patients seen in our center from 1984 to 1996, analyzing the records of those patients who underwent neuroimaging before or after the introduction of the IHS criteria in 1988. RESULTS: There were no differences in the number of CT scans ordered in the period before (6.04%) or after (6.06%) the introduction of the IHS criteria. Only 12 scans revealed significant abnormalities, probably unrelated to headache. CONCLUSIONS: These results suggest that the yield of CT scanning patients seen in a headache clinic is very low, even when alarm signs are present notwithstanding strict adherence to dignostic criteria. An improved definition of secondary forms of headache might help to reduce this adjunctive cost to the care of patients with headache in a headache clinic.     

涎腺导管癌CT及MRI影像特征分析

目的 观察涎腺导管癌(salivary duct carcinoma,SDC)患者的CT、MRI表现,探讨其影像学特征.方法 回顾性分析经手术组织病理证实的32例SDC患者的影像学、临床及病理资料,观察其部位、大小、形态、边界、与周围组织关系、密度、信号、强化方式、钙化、囊变及转移情况等.结果 32例SDC患者中,31...     

PET/CT、头部增强CT和头部增强MRI对肺癌脑转移瘤检出价值的对比

目的  分析与探讨¹⁸F-FDG PET/CT+头部增强CT、¹⁸F-FDG PET/CT+头部增强MRI几种检查方法对肺癌脑转移瘤的诊断价值与差异。方法  回顾分析327例肺癌患者的临床资料,对比其¹⁸F-FDG PET/CT、头部增强CT及头部增强MRI影像资料,分析¹⁸F-FDG PET/CT联合头部增强CT、¹⁸F-FDG PET/CT联合头部增强MRI对肺癌分期的影响;比较¹⁸F-FDG PET/CT、头部增强CT、头部增强MRI 3种检查方法对肺癌脑转移瘤检出价值;比较¹⁸F-FDG PET/CT与头部增强MRI,肺癌脑转移瘤漏诊组与未漏诊组囊变、水肿表现的差异。结果  ¹⁸F-FDG PET/CT+头部增强CT、¹⁸F-FDG PET/CT+头部增强MRI这两种组合检查方法在检出肺癌脑转移瘤方面,对肺癌分期的影响差异有统计学意义（χ²=305.58,P < 0.01）;¹⁸F-FDG PET/CT、头部增强CT、头部增强MRI三种检查方法对肺癌脑转移瘤检出率分别为7.34%、12.23%、19.88%;3种检查方法对肺癌脑转移瘤检出情况比较差异具有统计学意义（χ²=22.867,P < 0.01）;肺癌脑转移瘤¹⁸F-FDG PET/CT与MRI比较漏诊组与未漏诊组发生囊变、水肿情况的差异无统计学意义（χ²=0.657,P > 0.05;χ²=0.023,P > 0.05）;漏诊组、未漏诊组出现囊变率为31.70%（13/41）、41.67%（10/24）;漏诊组、未漏诊组出现水肿率为56.09%（23/41）、54.17%（13/24）。结论  ¹⁸F-FDG PET/CT+头部增强CT、¹⁸F-FDG PET/CT+头部增强MRI检查均能够提高肺癌脑转移瘤的检出率,对精确判断肺癌分期,掌握脑转移瘤详细情况,降低脑转移瘤的漏诊率有重要作用,检出价值最高的是¹⁸F-FDG PET/CT+头部增强MRI联合。     

临床采用CT与MRI诊断股骨头缺血坏死的价值比较

目的:研究股骨头缺血坏死诊断中应用CT与MRI的效果。方法:在2016年8月至2019年4月期间,选取114例于我院收治的股骨头缺血坏死患者为研究对象,分别采取CT与MRI诊断,对比患者诊断结束后股骨头缺血坏死的检出率。结果:经诊断,MRI诊断后股骨头缺血坏死检出率高于CT诊断,数据对比有差异,P<0.05。结论:对于股骨头缺血坏死的临床诊断中,采取MRI诊断的检出率较CT诊断高,可以为后期治疗提供准确依据,有应用价值。     

Novel cardiovascular MRI and CT methods for evaluation of ischemic heart disease

New developments in cardiac MRI and multidetector CT (MDCT) have generated tremendous excitement for both physicians and the general public. Their roles in the diagnostic algorithm of patients with suspected coronary artery disease are rapidly evolving. In addition to cardiac catheterization, nuclear imaging techniques and cardiac echocardiography, MDCT and MRI will play increasing roles in the diagnosis of ischemic heart disease. In this review we outline imaging techniques and illustrate the various applications of cardiac MRI and MDCT in the assessment of myocardial ischemia.     

CT与核磁共振技术在诊断股骨头坏死的对比研究

目的:对比C T与磁共振技术(M R I)诊断股骨头坏死的准确率.方法:选取2019年6月—2020年4月我院收治的60例股骨头坏死患者(82髋)作为研究对象,所有患者均行C T检查及M R I检查,分析两种检查方法诊断股骨头坏死的准确率.结果:所有患者经手术病理证实均为股骨头坏死.术前经MRI检查诊断明确77例,诊断...     

原发性腹膜后脂肪肉瘤的CT和MRI表现(附五例报告)

本文报道了5例原发性腹膜后脂肪肉瘤并复习了有关文献,结果表明本病重要的CT和MRI征象是不均匀软组织肿物,内含脂肪,并压迫和侵犯附近器官。本文也简单地叙述了本病的病理学分类。     

胰腺肿瘤的磁共振成像诊断——与CT、B超对比研究

目的：评价磁共振成像在胰腺肿瘤诊断的价值。方法：本文通过对２５例有手术病理的胰腺病变进行ＭＲ检查，采用自旋回波Ｔ１和Ｔ２加权像对病变进行判断，并与ＣＴ和Ｂ超对比分析。结果：这三种影像方法对胰腺癌的诊断准确率均为７２．７％。胰腺癌的ＭＲ表现，无论在Ｔ１还是Ｔ２加权像上其信号改变无特点，且７８％的胰腺癌信号强度与正常的肝组织和胰腺接近，故ＭＲ无法区别胰腺癌或胰腺其它病变。但在Ｔ１加权像上，由于ＭＲ的组织分辨率高，因而无论是显示胰周脂肪，肠系膜上动静脉有无受侵，还是肝门、脾门、脾静脉有无受侵均较ＣＴ显示更佳。结论：我们认为ＭＲ对于胰腺肿瘤的诊断尚需进一步探讨，但对于判断肿瘤侵犯的范围则有较大的应用价值     

CT及MRI在股骨头坏死诊断中的应用价值

目的 比较CT与MRI在股骨头坏死诊断中的应用价值.方法 纳入985例股骨头坏死患者的病历资料,分别给予CT诊断与MRI诊断,比较两种诊断方式对股骨头坏死临床分期及典型征象检出情况.结果 MRI对Ⅰ～Ⅱ期股骨头坏死的检出率、总检出率高于CT,差异具有统计学意义(P<0.05).MRI对线样征、骨髓水肿以及骨小梁模糊征象...     

Pathogenesis of Posttraumatic Headache and Migraine: A Common Headache Pathway?

In recent years, research implicating biochemical abnormalities in various pathological conditions has spiraled. Headache is an area in which numerous research studies have been conducted examining biochemical alterations. We have noticed several similarities in biochemical changes reported to occur in migraine and in experimental traumatic brain injury. The most common symptom in mild head injury or mild traumatic brain injury is headache which, in many instances, resembles migraine but has a poorly understood pathophysiology. Biochemical mechanisms believed to be similar in both conditions include: increased extracellular potassium and intracellular sodium, calcium, and chloride; excessive release of excitatory amino acids; alterations in serotonin; abnormalities in catecholamines and endogenous opioids; decline in magnesium levels and increase in intracellular calcium; impaired glucose utilization; abnormalities in nitric oxide formation and function; and alterations in neuropeptides. In this paper, these preposed biochemical alterations will be reviewed and compared. Very similar alterations suggest posttraumatic headache associated with mild head injury and migraine may share a common headache pathway.     

MRI、CT影像学表现差异在肝脏孤立性坏死结节中的诊断价值

目的  探讨肝脏孤立性坏死结节(SNN)的MRI、CT影像学表现及诊断价值。 方法  选取2014年1月~2020年6月在我院就诊的肝脏SNN患者40例,其中接受MRI检查的22例患者作为MRI组,CT检查的18例患者作为CT组,分析MRI、CT诊断肝脏SNN的价值,同时分析单纯凝固性坏死型、伴液化性坏死型和多结节融合型病灶的MRI、CT影像学表现差异。 结果  MRI诊断肝脏SNN准确率为95.45%,明显高于CT组(P < 0.05);CT组,单纯凝固性坏死型、伴液化性坏死型和多结节融合型病灶CT平扫及增强扫描表现差异无统计学意义(P>0.05),单纯凝固性坏死型、伴液化性坏死型和多结节融合型病灶CT平扫主要呈低密度影,分别占83.33%、42.86%和40.00%,3种病灶均无强化,其中分别有83.33%、57.14%和80.00%病灶包膜延迟强化;MRI组,伴液化性坏死型T2WI序列低信号比例高于单纯凝固性坏死型和多结节融合型(P < 0.05),多结节融合型T2WI序列稍高信号比例高于伴液化性坏死型(P < 0.05),单纯凝固性坏死型、伴液化性坏死型和多结节融合型病灶T1WI序列低信号比例均为100.00%,T2WI序列低信号鉴别伴液化性坏死型SNN的敏感度为100.00%,特异性为78.57%,准确率为86.36%,阳性预测值为72.73%,阴性预测值为100.00%;T2WI序列序列稍高信号鉴别伴液化性坏死型鉴别多结节融合型SNN的敏感度为100.00%,特异性为68.75%,准确率为77.27%,阳性预测值为54.55%,阴性预测值为100.00%,单纯凝固性坏死型、伴液化性坏死型和多结节融合型动脉期、门脉期和延迟期病灶无强化比例均为100.00%,但延迟期所有病灶边缘有强化。 结论 MRI和CT在肝脏SNN诊断中有一定应用价值,其中MRI诊断价值较好。     

Cluster Headache Following Head Injury: A Case Report and Review of the Literature

A relation between head trauma and cluster headache is frequently described in the literature. The percentage of cluster patients with a history of head injury is approximately 16.5 when several large studies are reviewed. The present paper reports another case where there is close proximity between head injury and the onset of cluster headache. A review of the literature attempts to document the supposition that there is indeed a causal or precipitous role for head injury in cluster cephalgia pathogenesis.     

Future of advanced guidance techniques by interventional CT and MRI

Summary

Minimally invasive techniques using endoscopes for image-guided therapy are common in the surgical field and in internal medicine. Interventional procedures in the past were performed with either fluoroscopic, sono-graphic or CT-guidance, but now MRI-guided interventional procedures are being developed. Combining these technologies will improve surgical access and reduce complications. In today's minimally invasive therapy, tomography technology (CT, EBT, MRI) can be used for precise and transparent guidance of endoscopes and surgical instruments inside the body. This will offer a safe and effective access into the body, especially in high risk areas and lead to the new field of ‘Surgical Tomography'.