C3-C4 cervical disc herniation producing Brown-Séquard syndrome: A case report and review of the literature.

Brown-Séquard Syndrome (BSS) is a rare form of incomplete spinal cord injury and is characterized by ipsilateral motor deficit and contralateral sensory loss. BSS is commonly associated with traumatic etiologies, but non-traumatic causes should be considered as well. A 38-year-old woman presented with a 3-week history of weakness in her right upper extremity, and she has developed numbness and tingling in her left upper and lower extremities over the past week and a half, along with some motor difficulty. Imaging showed a large right paracentral disc protrusion at the C3-C4 level causing severe spinal canal narrowing and resulting in abnormal cord signal. The patient subsequently underwent a C3-4 cervical total disk replacement. Hemovac placed during surgery was removed on post-op day one, and she was re-evaluated by PT/OT and recommended for outpatient therapies on post-op day two. Our case, along with a review of the literature, highlights those non-traumatic causes of BSS should be considered as a cause of BSS. BSS produced by a herniated cervical disc is extremely rare and is often misdiagnosed.

Anterior ischemic stroke: Analysis of the multivariable CT-based models for prediction of clinical outcome.

OBJECTIVE: To determine the predictive value of multiple CT-based measurements, individually and collectively, including arterial collateral filling (AC), tissue perfusion parameters, as well as cortical venous (CV) and medullary venous (MV) outflow, in patients with acute ischemic stroke (AIS). METHODS: We retrospectively reviewed a database of patients with AIS in the middle cerebral artery distribution, who underwent evaluation by multiphase CT-angiography and perfusion. AC pial filling was evaluated using a multiphase CTA imaging. The CV status was scored using the adopted PRECISE system based on contrast opacification of the main cortical veins. The MV status was defined by the degree of contrast opacification of medullary veins in one cerebral hemisphere as compared to the contralateral hemisphere. The perfusion parameters were calculated using FDA-approved automated software. A good clinical outcome was defined as a Modified Rankin Scale of 0-2 at 90 days. RESULTS: A total of 64 patients were included. Each of the CT-based measurements could predict clinical outcomes independently (P<0.05). AC pial filling and perfusion core based models did slightly better compared to each of the other models (AUC = 0.66). Among models with two variables, the perfusion core combined with MV status had the highest AUC=0.73 followed by a combination of MV status and AC (AUC=0.72). Multivariable modeling with all four variables resulted in the highest predictive value (AUC=0.77). CONCLUSION: The combination of arterial collateral flow, tissue perfusion, and venous outflow provides a more accurate prediction of clinical outcome in AIS than each variable alone. This additive effect of these techniques suggests that the information collected by each of these methods only partially overlaps.

The Significance of Arachnoid Granulation in Patients With Idiopathic Intracranial Hypertension.

PURPOSE: The aim of this article was to study the significance of arachnoid granulations (AGs) in patients with idiopathic intracranial hypertension (IIH). METHODS: In an institutional review board-approved retrospective chart review study, 79 patients with clinical diagnosis of idiopathic increased intracranial pressure were compared with 63 patients with a diagnosis of multiple sclerosis. Inclusion criteria also included available magnetic resonance imaging (MRI) of the brain, older than 18 years, and female sex. Patients with elevated intracranial pressure due to other causes were excluded. The electronic medical records were mined for presence of the following: body mass index, age, headache, vision changes, tinnitus, and vertigo. The MRI of the brain was reviewed for the presence of the following features: empty sella, prominent cerebrospinal fluid space in the optic sheaths, tortuosity of the optic nerves and enlarged Meckel cave. In addition, the number, size, and location of AGs associated with major venous drainage sinuses were documented in all patients. Using statistical analysis, association between various imaging and clinical signs were evaluated. RESULTS: The association between AG and various imaging and clinical signs were evaluated. The percentage of patients with AG were significantly higher in patients with IIH. Patients with IIH tended to have 0 to 3 AG. The most common imaging findings observed in MRI of the brain of patients with IIH were empty sella and prominent cerebrospinal fluid space in the optic sheaths. The prevalence of these MRI findings in patients with IIH was inversely proportional to the number of AG. A similar inverse trend was also noted with the opening pressure of patients with IIH and number of AG. CONCLUSIONS: The study establishes that there is a relationship between presence of AG and IIH. Arachnoid granulation seems to act in a compensatory mechanism in patients with IIH.

Orbital malignant meningioma: a unique presentation of a rare entity.

An elderly female with progressive proptosis was found to have an aggressive retrobulbar solid orbital mass. The mass was distinct from the optic nerve sheath and intracranial meninges, and produced concave erosion of the sphenoid wing. Operative findings demonstrated an orbital mass adherent to the dura of the superior orbital fissure. The mass did not demonstrate meningeal violation, infiltrate the superior orbital fissure, or display intracranial spread. The dura remained intact after gross total resection. Histopathology revealed a malignant meningioma with papillary and focal rhabdoid morphology and bony invasion (WHO grade III). The patient received 2500cGy of stereotactic radiotherapy in addition to gross total resection. Postoperatively, the signs and symptoms of orbital mass effect resolved (proptosis, relative afferent papillary defect, and periorbital edema) and the vision improved. There was no orbital recurrence or intracranial extension. The follow-up time was limited to eight months secondary to the patient succumbing to metastatic lung adenocarcinoma, which was demonstrated to be a separate process from the orbital meningioma. We propose the etiology of this tumor to be most consistent with an orbital malignant primary extradural meningioma - the first case reported in the literature.

Orbital blowout fractures: a novel CT measurement that can predict the likelihood of surgical management.

OBJECTIVE: The purpose of this study is to identify an accurate and reliable computed tomographic (CT) measurement that can identify those patients presenting to the emergency department (ED) with orbital floor fracture (BOF) who require surgical repair to prevent ensuing visually debilitating diplopia and/or enophthalmos. METHODS: In this retrospective institutional review board-approved study, we reviewed 99 patients older than 18 years with orbital fractures treated in a level I trauma center from 2011 through 2015. Thirty-three patients met the inclusion criteria of having an isolated BOFs with or without a minimally displaced medial wall fracture. The maxillofacial CT of these patients, which included axial, coronal, and sagittal reconstruction of the face in both soft tissue and bone algorithm, were independently reviewed by a neuroradiologist and an oculoplastic surgeon. Each reviewer analyzed the images to answer the following 3 questions: (1) extent of the fracture fragment; greater than or less than 50%? (2) involvement of the inframedial strut (IMS)? and (3) cranial-caudal discrepancy of the orbits. This novel measurement was defined as the difference between the cranial-caudal dimension (CCD), measured just posterior to the globe, of the fractured orbit minus the CCD of the normal side. Electronic medical record was reviewed to determine the course of recovery, ophthalmologist assessment of the globe, motility, diplopia, and the need for operative repair. Statistical analysis was performed to determine the accuracy of the measured CT parameters for the prediction of those who would ultimately require surgical repair. RESULTS: Of the 33 patients included in the study, 8 patients required surgical correction of their BOFs. Others were managed conservatively. The accuracy of BOF > 50% for predicting those requiring surgical repair was 48%. The accuracy of IMS involvement was 74%. Using a threshold CCD value of 0.8 cm, the accuracy of CCD was 94%. Cranial-caudal discrepancy had a sensitivity of 100% and specificity of 92%. κ Agreement between the 2 readers evaluating the CT images was 0.93. CONCLUSION: Initial maxillofacial CT studies obtained in the ED for those with BOF is used to predict which patients may need urgent surgical repair. In this report, we introduce a new CT measurement, called CCD. Cranial-caudal discrepancy greater than 0.8 cm is predictive of the development of diplopia and/or enophthalmos that will require surgical correction. Orbital floor fracture greater than 50% and IMS involvement were much less accurate in making similar predictions. Cranial-caudal discrepancy should be used by the ED physicians to identify those patients who should be referred sooner than later to an oculoplastic surgeon for surgical evaluation and intervention. Correct and timely triaging can prevent the complications of delayed correction including scarring, difficult surgical repair, and/or poor functional and aesthetic outcomes.

Small subdural hemorrhages: is routine intensive care unit admission necessary?

With advancing technology, the sensitivity of computed tomography (CT) for the detection of subdural hematoma (SDH) continues to improve. In some cases, the finding is limited to one or 2 images of the CT examination. At our institution, all patients with an SDH require intensive care unit (ICU) admission, regardless of size. In this report, we tested the hypothesis that patients with a small traumatic SDH on their presenting CT examination do not require the intensive monitoring offered in the ICU and can instead be managed on a hospital unit with a lower level of monitoring. This is a retrospective study of patients evaluated and treated at a level I trauma center for acute traumatic intracranial hemorrhage between 2011 and 2014. The clinical and imaging profile of 87 patients with traumatic SDH were studied. Patients with small isolated traumatic subdural hemorrhage (tSDH) (<10 cm(3) blood volume) spent less time in the ICU, demonstrated neurologic and medical stability during hospitalization, and did not require any neurosurgical intervention. It is our recommendation that patients with isolated tSDH (<10 cm(3)) do not require ICU monitoring. Patients with small tSDH and additional intracranial hemorrhages overall show low rates of medical decline (4%) and neurologic decline (4%) but may still benefit from ICU observation. Patients with tSDH greater than 10 cm(3) overall demonstrated poor clinical courses and outcome and would benefit ICU monitoring.

The clinical significance of small subarachnoid hemorrhages.

With advancing technology, the sensitivity of computed tomography (CT) for the detection of traumatic subarachnoid hemorrhage (tSAH) continues to improve. Increased resolution has allowed for the detection of hemorrhage that is limited to one or two images of the CT exam. At our institution, all patients with a SAH require intensive care unit (ICU) admission, regardless of size. It was our hypothesis that patients with small subarachnoid hemorrhage experience favorable outcomes, and may not require the intensive monitoring offered in the ICU. This retrospective study evaluated 62 patients between 2011 and 2014 who presented to our Level I trauma center emergency room for acute traumatic injuries, and found to have subarachnoid hemorrhages on CT examination. The grade of subarachnoid hemorrhage was determined using previously utilized scoring systems, such as the Fisher, Modified Fisher, and Claassen grading systems. Electronic medical records were used to evaluate for medical decline, neurological decline, neurosurgical intervention, and overall hospital course. Admitting co-morbidities were noted, as were the presence of patient intoxication and use of anticoagulants. Patient outcomes were based on discharge summaries upon which the neurological status of the patient was assessed. Each patient was given a score based on the Glasgow outcome scale. The clinical and imaging profile of 62 patients with traumatic SAH were studied. Of the 62 patients, 0 % underwent neurosurgical intervention, 6.5 % had calvarial fractures, 25.8 % had additional intracranial hemorrhages, 27.4 % of the patients had significant co-morbidities, and 1.6 % of the patients expired. Patients with low-grade tSAH spent less time in the ICU, demonstrated neurological and medical stability during hospitalization. None of the patients with low-grade SAH experienced seizure during their admission. In our study, patients with low-grade tSAH demonstrated favorable clinical outcomes. This suggests that patients may not require as aggressive monitoring as is currently provided for those with tSAH.

Semiquantitative and Quantitative Analyses of Dynamic Contrast-Enhanced Magnetic Resonance Imaging of Thyroid Nodules.

OBJECTIVE: This study was aimed to determine the utility of quantitative dynamic contrast-enhanced magnetic resonance imaging (MRI) in differentiating benign and malignant lesions in patients with known thyroid gland lesions scheduled for resection. METHODS: Patients scheduled for resection of a thyroid mass were prospectively enrolled. Dynamic contrast-enhanced MRI scans of the neck were performed before surgery. After resection, patients were divided into benign and malignant groups. Quantitative and semiquantitative MRI kinetic measurements of benign and malignant lesions were compared and analyzed. RESULTS: Twelve benign and 9 malignant lesions were identified in 19 patients. Mean Ktrans, Ve, and Kep for benign lesions were 1.69 ± 1.59 min, 0.44 ± 0.21 min, and 4.51 ± 2.96 min, respectively; for the malignant lesions, 0.96 ± 0.57 min, 0.45 ± 0.19 min, and 3.57 ± 3.53 min, respectively (P = 0.1886, 0.8036, and 0.3028, respectively). Tpeak, ERmax, slopemax, and iAUGC60 for benign lesions were 7.00 ± 8.09 seconds, 293.27 ± 141.25 seconds, 76.45 ± 65.80 seconds, and 63.46 ± 46.84, respectively; for malignant lesions, 8.11 ± 8.55 seconds, 227.6 ± 113.37 seconds, 81.17 ± 109.71 seconds, and 43.69 ± 26.19, respectively (P = 0.7525, 0.4941, 0.4474, and 0.3028, respectively). CONCLUSIONS: Dynamic contrast-enhanced MRI pattern of kinetics was not significantly different for benign and malignant lesions of the thyroid using quantitative or semiquantitative methods.

Emergent double valve replacement in Austrian syndrome.

Bi-valvular pneumococcal endocarditis in Austrian syndrome, which includes a triad of pneumococcal endocarditis, pneumonia, and meningitis, is a rare but life-threatening disease. We present a case of a woman found to have Austrian syndrome who presented to the emergency department (ED) with dehydration and radiographical signs of lobar pneumonia and quickly deteriorated to fulminant cardiogenic shock in less than four hours. An early echocardiogram in the ED confirmed a diagnosis of bi-valvular endocarditis with severe aortic and mitral valve insufficiency and large vegetations on the valve leaflets requiring emergent surgical intervention with double valve replacement. Assumed meningitis as a part of the triad of Austrian syndrome was confirmed by imaging the day after hospital admission. Early diagnosis of endocarditis by obtaining the echocardiogram in the ED along with emergent surgical intervention allowed for a favorable outcome for the patient.

Preventing cuff rupture during tracheostomy: importance of endotracheal tube positioning.

OBJECTIVE: The objective of our study is to describe the technique of distal endotracheal tube (ETT) positioning for avoiding cuff rupture and validate the technique in a virtual tracheostomy model. METHODS: A prospective nonrandomized case series of 129 patients who had undergone tracheostomy using the senior author's technique were evaluated. Primary outcome was ETT cuff rupture. One hundred normal patient computed tomography (CT) scans were used to generate a virtual tracheostomy model, and the probability of cuff rupture, among other values, was obtained. RESULTS: One hundred twenty-three of 129 patients underwent tracheostomy without cuff rupture when the distal tip of the ETT was placed just proximal to the carina. After analysis of 100 3-dimensional CT scans, the average distance from the tracheotomy to the superior aspect of the cuff was 54.6 mm in men and 39.87 mm in women when a 6.5-size ETT was used, and 44.8 mm in men and 30.07 mm in women when a 7.5-size ETT was used. Virtual tracheotomy between the second and third tracheal rings resulted in no probability of inadvertent ETT cuff rupture. CONCLUSION: Distal ETT positioning during tracheostomy should be considered for avoiding inadvertent ETT cuff rupture.

The vallecular line: an objective measure in evaluating the base of the tongue and vallecular cancers for transoral robotic surgery.

OBJECTIVE: We hypothesized that the degree of the exophytic nature of the base of the tongue and vallecular cancers (BOTs) impacts the feasibility of transoral resection. The growth pattern of these cancers can be measured by the vallecular line (VL), which is the distance between the hyoid bone and the vallecular tip. MATERIALS AND METHODS: The normal VL was measured by 3 radiologists on 50 magnetic resonance imaging scans. The VL was then measured on magnetic resonance imaging scans of patients with BOT cancers. RESULTS: The mean VL was 8.2 mm (6.4-10 mm) in the healthy patients. The mean VL of the patients with predominantly exophytic BOT cancer was 22.7 mm (20.6-24.8 mm). Postoperative images of these patients demonstrate minimal loss of the native tongue after transoral resection. CONCLUSIONS: The VL is a valuable objective measurement of the exophytic nature of BOT cancers. Predominantly exophytic BOT cancers are deemed more amenable for successful and functional transoral surgical resection.

Prevalence of vocal cord paralysis in patients with incidentally discovered enlarged lymph nodes along the expected course of the recurrent laryngeal nerve.

OBJECTIVES: We sought to determine the prevalence of vocal cord paralysis in patients with incidentally discovered lymphadenopathy along the expected course of the recurrent laryngeal nerve (RLN). METHODS: We reviewed the positron-emission tomographic (PET) and computed tomographic (CT) scans of 936 consecutive patients with a variety of diagnoses. Enlarged lymph nodes (short-axis diameter of more than 1 cm) along the expected course of the RLN were identified. Patients with lymphadenopathy were evaluated for CT signs of vocal cord paralysis. The medical records of patients with lymphadenopathy were reviewed for clinical signs of vocal cord paralysis. Patients with head and neck malignancies were excluded from the study. RESULTS: Lymphadenopathy along the course of the RLN was identified in 57 of the 936 patients studied. Fifty-three of the 57 patients (93%) were found to have a malignancy. Thirty-four enlarged nodes (60%) had FDG uptake as shown on a PET/CT scan. Twenty enlarged nodes (35%) had CT evidence of extracapsular spread. Four patients (7%) had CT evidence of vocal cord paralysis. One patient (2%) had clinical evidence of vocal cord paralysis. CONCLUSIONS: In asymptomatic patients with incidental lymphadenopathy along the course of the RLN, vocal cord paralysis is rare.

The role of arachnoid granulations in idiopathic intracranial hypertension.

OBJECTIVES: Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure (ICP) without an established etiology. Arachnoid granulations (AG) are conduits for CSF resorption from the subarachnoid space to the venous system. AG have been implicated to play a central role in maintaining CSF homeostasis. We tested the hypothesis that patients with fewer visible AG on MRI are more likely to present with IIH. METHODS: In this institutional review board (Institutional Review Board)-approved retrospective chart review study, 65 patients with a clinical diagnosis of idiopathic intracranial hypertension were compared to 144 control patients who met inclusion/exclusion criteria. Patients' signs and symptoms pertaining to IIH were obtained through the electronic medical record Brain MR images were reviewed for the number and distribution of AGs indenting the dural venous sinuses. The presence of imaging and clinical findings associated with long standing increased ICP was noted. Propensity score method (with inverse probability weighting technique) was used to compare case and control groups. RESULTS: In the control group, the number of AG indenting the dural venous sinuses on MRI (NAG) was lower in women compared to men when matched for age (20-45 yo) and BMI (>30 kg/m2). The NAG was lower in 20-45 yo females in the IIH group as compared to the 20-45 yo females in the control group. This statistically significant difference persists when controlled for BMI. In contrast, the NAG in >45 yo females in the IIH group trended higher compared to the >45 yo females in the control group. CONCLUSION: Our results suggest that alterations in arachnoid granulations could play a role in the development of IIH.

ACR Appropriateness Criteria® Staging and Post-Therapy Assessment of Head and Neck Cancer.

Imaging of head and neck cancer at initial staging and as part of post-treatment surveillance is a key component of patient care as it guides treatment strategy and aids determination of prognosis. Head and neck cancer includes a heterogenous group of malignancies encompassing several anatomic sites and histologies, with squamous cell carcinoma the most common. Together this comprises the seventh most common cancer worldwide. At initial staging comprehensive imaging delineating the anatomic extent of the primary site, while also assessing the nodal involvement of the neck is necessary. The treatment of head and neck cancer often includes a combination of surgery, radiation, and chemotherapy. Post-treatment imaging is tailored for the evaluation of treatment response and early detection of local, locoregional, and distant recurrent tumor. Cross-sectional imaging with CT or MRI is recommended for the detailed anatomic delineation of the primary site. PET/CT provides complementary metabolic information and can map systemic involvement. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Tinnitus: 2023 Update.

Tinnitus is abnormal perception of sound and has many subtypes. Clinical evaluation, audiometry, and otoscopy should be performed before ordering any imaging, as the choice of imaging will depend on various factors. Type of tinnitus (pulsatile or nonpulsatile) and otoscopy findings of a vascular retrotympanic lesion are key determinants to guide the choice of imaging studies. High-resolution CT temporal bone is an excellent tool to detect glomus tumors, abnormal course of vessels, and some other abnormalities when a vascular retrotympanic lesion is seen on otoscopy. CTA or a combination of MR and MRA/MRV are used to evaluate arterial or venous abnormalities like dural arteriovenous fistula, arteriovenous malformation, carotid stenosis, dural sinus stenosis, and bony abnormalities like sigmoid sinus wall abnormalities in cases of pulsatile tinnitus without a vascular retrotympanic lesion. MR of the brain is excellent in detecting mass lesions such as vestibular schwannomas in cases of unilateral nonpulsatile tinnitus. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Lemierre's syndrome and rapidly deteriorating respiratory failure in the emergency department.

Rapidly progressive acute respiratory distress along with life-threatening gram-negative anaerobic sepsis in a young, immunocompetent individual should always raise concern for Lemierre's syndrome. Although still rare, the incidence of Lemierre's syndrome has been increasing over the past 20 years. Lemierre's syndrome is characterized by postanginal septicemia and secondary internal jugular vein suppurative thrombophlebitis. In the emergency department (ED), patients often present with evidence of sepsis and secondary septic emboli to different organs, primarily the lungs.We report a case of a 24-year-old patient who presented to the ED with acute respiratory distress with an atypical and rapidly deteriorating course. She was later diagnosed with Lemierre's syndrome and recovered well after antibiotic treatment, respiratory support, and a lengthy intensive care unit stay. This case report represents an atypical presentation of acute respiratory distress and pharyngitis but is classic for Lemierre's syndrome.

ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update.

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey.

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Cranial Neuropathy: 2022 Update.

Cranial neuropathy can result from pathology affecting the nerve fibers at any point and requires imaging of the entire course of the nerve from its nucleus to the end organ in order to identify a cause. MRI with and without intravenous contrast is often the modality of choice with CT playing a complementary role. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.