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MRA (Magnetic Resonance Angiogram) Head 70544 70545 70546

1.1.1 See Vertebrobasilar Insufficiency

1.2 Calvarial (skull) mass

1.2.1 See Central Venous Thrombosis

1.3.1 Prior history of stroke or TIA

1.3.2 Suspected Vetebrobasilar Insufficiency: See under Working Daignosis

Johnson, K A et al Brain imaging in Alzheimer disease. Cold Spring Harb Perspect Med >v.2(4); Apr 2012

Kantarci K, Jack CR Jr. Neuroimaging in Alzheimer disease: an evidence-based review. Neuroimaging Clin N Am. 2003 May; 13(2):197-209.

1.4 Disorientation (cognitive change)

1.4.1 See Cognitive Changes

1.5.1 NOTE: “The life-time prevalence of dizziness in general population is estimated from 5.5% to 25-30% in the United States depending on the criteria adopted (Kroenke and Mangelsdorff, 1989; Colledge et al., 1994; Yardley et al., 1998b).”

1.5.2.1 Altered mental state

1.5.2.2 Cranial neuropathies

1.5.2.3 Diabetes mellitus, by history

1.5.2.4 Hearing Loss

1.5.2.5 Loss of vision

1.5.2.6 Nausea or Vomiting

1.5.2.7 Nystagmus

1.5.2.8 Stroke, prior history of

1.5.2.9 Tinnitus

1.5.2.10 Weakness or paralysis

Kevin Barraclough, Adolfo Bronstein Vertigo BMJ 2009;339:b3493, doi: 10.1136/bmj.b3493 (Published 22 September 2009) http://www.bmj.com/content/vol339/issuesep22_1/images/large/bark673889.f1_default.jpeg

David E. Newman-Toker, et al; Spectrum of Dizziness Visits to US Emergency Departments: Cross-Sectional Analysis From a Nationally Representative Sample; Mayo Clin Proc. July 2008 83(7):765-775; doi:10.4065/83.7.765

C S K Cheung, P S K Mak, K V Manley, J M Y Lam, A Y L Tsang, H M S Chan, T H Rainer, C A Graham Predictors of important neurological causes of dizziness among patients presenting to the emergency department Emerg Med J 2010;27:517-521 doi:10.1136/emj.2009.078014

Ropper AH, Brown RH, “Chapter 15. Deafness, Dizziness, and Disorders of Equilibrium” (Chapter). Ropper AH, Brown RH: Adams and Victor’s Principles of Neurology, 8th Edition

Daroff Robert B, “Chapter 22. Dizziness and Vertigo” (Chapter). Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J: Harrison’s Principles of Internal Medicine, 17th Edition: http://www.accessmedicine.com/content.aspx?aID=2886671

Jeffrey P. Staab; Michael J. Ruckenstein Expanding the Differential Diagnosis of Chronic Dizziness Arch Otolaryngol Head Neck Surg. 2007;133(2):170-176.

Irwin Nazareth , Lucy Yardley , Natalie Owen , and Linda Luxon Outcome of symptoms of dizziness in a general practice community sample Fam. Pract. 16: 616-618.

M Wasay, N Dubey, and R Bakshi Emerg Dizziness and yield of emergency head CT scan: Is it cost effective? Med J. 2005 April; 22(4): 312. doi: 10.1136/emj.2003.012765. PMCID: PMC1726733

Ramos, R Antidepressants and Dizziness Journal of Psychopharmacology 20:5 (sept 2003) p 708

1.6 Double vision, Diplopia

1.6.1 See Vertebrobasilar Insufficiency

1.7 Dysphagia

1.7.1 See Vertebrobasilar Insufficiency

1.8 Impaired ability to speak. Dysarthria – (due to CNS disorder)

1.9 Seizures, Focal or generalized

1.9.1 See Central Venous Thrombosis

1.10 Headache

1.10.1 Thunderclap (sudden onset and severe)

1.10.2 Exertional

1.10.3 Pregnancy, New Onset during

1.10.4 Prior history of HIV or malignancy

1.10.5 Changed pattern (Chronic headache with new features)

1.10.6 Repeated headaches beginning after age 50

1.11 Hearing Loss

1.11.1 See Vertebrobasilar Insufficiency

1.12 Hemiparesis or paraparesis

1.12.1 See Central Venous Thrombosis

1.13 Lethargy or Coma

1.13.1 See Central Venous Thrombosis

1.14.1 Prior history of stroke or TIA

1.14.2 Suspected Vetebrobasilar Insufficiency: See under Working Daignosis

1.15.1 Prior history of stroke or TIA

1.15.2 Suspected Vetebrobasilar Insufficiency: See under Working Daignosis

1.16 Nausea

1.16.1 See Vertebrobasilar Insufficiency

1.17 Numbness

1.17.1 See Vertebrobasilar Insufficiency

1.18 Nystagmus

1.18.1 See Vertebrobasilar Insufficiency

1.19 Syncope

1.19.1 See Vertebrobasilar Insufficiency

1.20.1.1 Suggest MRI with gadolinium

1.20.2.1 Suggest CTA or MRA of the brain, can also approve contrast enhanced CT

Lockwood, Alan H., Salvi, Richard J., Burkard, Robert F. Tinnitus N Engl J Med 2002 347: 904-910

Jane L. Weissman and Barry E. Hirsch Imaging of Tinnitus: A Review Radiology August 2000 216:2 342-349

1.21.1 See Central Venous Thrombosis

1.22.1.1 Altered mental state

1.22.1.2 Diabetes mellitus, by history

1.22.1.3 Hearing Loss

1.22.1.4 Loss of vision

1.22.1.5 Nausea or Vomiting

1.22.1.6 Nystagmus

1.22.1.7 Stroke, prior history of

1.22.1.8 Weakness or paralysis

1.23 Vision Loss

1.23.1 See Vertebrobasilar Insufficiency

1.24.1 See Vertebrobasilar Insufficiency

1.25 Vomiting

1.25.1 See Central Venous Thrombosis

1.25.2 See Vertebrobasilar Insufficiency

1.26.1 See Vertebrobasilar Insufficiency

2.1.1 Autosomal Polycystic Kidney Disease

2.1.2 Carotid Stenosis by Ultrasound

2.1.3 Family history of at least two relatives with subarachnoid hemorrhage

2.1.4 Family history of Cerebral Aneurysm

2.1.5 Family history of multiple Meningiomas

2.1.6 Family history of Polycystic Kidney Disease

2.1.7 Isolated cranial nerve (CN) deficit

Stefan Graf , Alexander Schischma , Knut E. Eberhardt , Roland Istel , Birgit Stiasny , and Bernd D. Schulze Intracranial aneurysms and dolichoectasia in autosomal dominant polycystic kidney disease Nephrol. Dial. Transplant. 17: 819-823. Laura M. Héman, Lisa M. Jongen, H. Bart van der Worp, Gabriel J.E. Rinkel, and Jeroen Hendrikse Incidental Intracranial Aneurysms in Patients With Internal Carotid Artery Stenosis: A CT Angiography Study and a Metaanalysis Stroke 40: 1341-1346

Chapman, AB, Rubinstein, D, Hughes, R, Stears, JC, Earnest, MP, Johnson, AM, Gabow, PA, Kaehny, WD Intracranial aneurysms in autosomal dominant polycystic kidney disease N Engl J Med 1992 327: 916-920 A. Stijntje E. Bor, Hendrik Koffijberg, Marieke J.H. Wermer, and Gabriel J.E. Rinkel Optimal screening strategy for familial intracranial aneurysms: A cost-effectiveness analysis Neurology May 25, 2010 74:1671-1679 H.W. Xu, Sheng Qiang Yu, Chang Lin Mei, and Ming Hua Li Screening for Intracranial Aneurysm in 355 Patients With Autosomal-Dominant Polycystic Kidney Disease Stroke 42: 204-206 recommends MRA as better screening exam Juvela S, Porras M, Heiskanen O. Natural history of unruptured intracranial aneurysms: a long-term follow-up study. J Neurosurg 1993;79:174-182

Atlas S, Sheppard L, Goldberg HI, Hurst RW, Listerud J, Flamm E. Intracranial aneurysms: detection and characterization with MR angiography with use of an advanced postprocessing technique in a blinded-reader study. Radiology 1997;203:807-814 Chapman, AB, Rubinstein, D, Hughes, R, Stears, JC, Earnest, MP, Johnson, AM, Gabow, PA, Kaehny, WD Intracranial aneurysms in autosomal dominant polycystic kidney disease N Engl J Med 1992 327: 916-920

Marieke J.H. Wermer, Gabriël J.E. Rinkel, and Jan van Gijn Repeated Screening for Intracranial Aneurysms in Familial Subarachnoid Hemorrhage Stroke 2003 34: 2788-2791; The International Study of Unruptured Intracranial Aneurysms Investigators,Unruptured Intracranial Aneurysms — Risk of Rupture and Risks of Surgical Intervention N Engl J Med 1998 339: 1725-1733

Laura M. Héman, Lisa M. Jongen, H. Bart van der Worp, Gabriel J.E. Rinkel, and Jeroen Hendrikse Incidental Intracranial Aneurysms in Patients With Internal Carotid Artery Stenosis: A CT Angiography Study and a Metaanalysis Stroke, Apr 2009; 40: 1341 – 1346. “About 1% of patients with a symptomatic ICA stenosis have an intracranial aneurysm with a higher than negligible risk of rupture…” David O. Wiebers, David G. Piepgras, Fredric B. Meyer, David F. Kallmes, Irene Meissner, John L. D. Atkinson, Michael J. Link, and Robert D. Brown, Jr Pathogenesis, Natural History, and Treatment of Unruptured Intracranial Aneurysms Mayo Clin. Proc., Dec 2004; 79: 1572 – 1583. MR angiography and surgery for unruptured familial intracranial aneurysms in persons with a family history of cerebral aneurysms Am. J. Roentgenol. 1999 173: 133-138 Francesca Crawley, Andrew Clifton, and Martin M. Brown Should We Screen for Familial Intracranial Aneurysm? Stroke 30: 312-316

2.2.1.1 Calvarial mass

2.2.1.2 Decreased vision

2.2.1.3 Exophthalmous

2.2.1.4 Focal neurologic deficits

2.2.1.5 Focal or generalized seizures

2.2.1.6 Headache

2.2.1.7 Hemiparesis or paraparesis

2.2.1.8 Lethargy or Coma

2.2.1.9 Mental status changes

2.2.1.10 Papilledema

2.2.1.11 Seizure

2.2.1.12 Transient visual deficits

2.2.1.13 Vomiting

2.2.1.14 Weakness, localized to a single extremity

2.2.2.1 Cancer

2.2.2.2 Contraceptive medications

2.2.2.3 Dehydration

2.2.2.4 Erythropoetin Use

2.2.2.5 Hypercoagulable state

2.2.2.6 Infections: Sinusitis, middle ear or systemic

2.2.2.7 Marasmus

2.2.2.8 Meningitis

2.2.2.9 Post operative status

2.2.2.10 Post Partum

2.2.2.11 Pregancy

2.2.2.12 Skull fracture over dural sinus

2.2.2.13 Tamoxifen Use

2.3.1.1 Amaurosis fugax

2.3.1.2 Amnesia

2.3.1.3 Aphasia, sudden onset of

2.3.1.4 Ataxia

2.3.1.5 Cognitive changes

2.3.1.6 Conjugate gaze paralysis

2.3.1.7 Cortical blindness

2.3.1.8 Diplopia

2.3.1.9 Disorientation (cognitive change)

2.3.1.10 Dizziness or vertigo with any other neurological sign

2.3.1.11 Double vision, Diplopia

2.3.1.12 Drop Attack

2.3.1.13 Dysarthria

2.3.1.14 Dysphagia

2.3.1.15 Facial numbness or paresthesias

2.3.1.16 Facial pain, unilateral

2.3.1.17 Focal neurologic deficit, sudden onset of

2.3.1.18 Hand spasms

2.3.1.19 Headache, may be unilateral

2.3.1.20 Hearing Loss

2.3.1.21 Homonymous hemianopia

2.3.1.22 Intention tremor

2.3.1.23 Loss of vision,

2.3.1.24 Memory loss (cognitive change)

2.3.1.25 Motor speech disorder

2.3.1.26 Nausea

2.3.1.27 Neck pain

2.3.1.28 Numbness

2.3.1.29.1 Definition: repetitive, rhythmic oscillations of one or both eyes in any or all fields of gaze

2.3.1.30 Oculosympathetic palsey (miosis and ptosis)

2.3.1.31 Ophthalmoplegia

2.3.1.32 Paralysis, of tongue

2.3.1.33 Paralysis, sudden onset of

2.3.1.34 Sensory changes, sudden onset of

2.3.1.35 Syncope

2.3.1.37.1 Vertigo requires the patient to experience a sense of spinning, of either the patient, or the surroundings. it is more than dizziness, lightheadedness or imbalance.

2.3.1.38 Visual Changes

2.3.1.39 Vomiting

2.3.1.40 Weakness involving structures on one or both sides of the body

2.3.1.41 Weakness, sudden onset of

2.3.2 Risk Factor for Vertebrobasilar Insufficiency ANY ONE:

2.3.2.1 Autosomal Polycystic Kidney Disease

2.3.2.2 Cardiac irregularities

2.3.2.3 Chronic HTN

2.3.2.4 Circulation problems in other parts of the body

2.3.2.5 Diabetes

2.3.2.6 Drug use

2.3.2.7 Heart disease

2.3.2.8 Hypercholesterolemia

2.3.2.9 inflammatory disorder of the carotid wall

2.3.2.10 Severe anemia

2.3.2.11 Smoker

2.3.2.12 VERY low BP

2.3.3.1 Barnett HJ, Taylor DW, Eliasziw M, et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis: North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339:1415-1425

2.3.3.2 Mark J.W. Koelemay, Paul J. Nederkoorn, Johannes B. Reitsma, and Charles B. Majoie Systematic Review of Computed Tomographic Angiography for Assessment of Carotid Artery Disease Stroke 35: 2306-2312

2.3.3.3 Constantine C. Phatouros, Randall T. Higashida, Adel M. Malek, Philip M. Meyers, Todd E. Lempert, Christopher F. Dowd, and Van V. Halbach Carotid Artery Stent Placement for Atherosclerotic Disease: Rationale, Technique, and Current Status Radiology 2000

2.3.3.4 Josephson, S. A., Bryant, S. O., Mak, H. K., Johnston, S. C., Dillon, W. P., Smith, W. S. Evaluation of carotid stenosis using CT angiography in the initial evaluation of stroke and TIA Neurology 2004 63: 457-460

2.3.3.5 Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005; 352:2618.

2.3.3.6 Searls DE, Pazdera L, Korbel E, et al. Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol 2012; 69:346

2.4.1.1 See Vertebrobasilar Insufficiency

2.4.2.1 See Vertebrobasilar Insufficiency

2.4.4.1 See Vertebrobasilar Insufficiency

2.4.5.1 See Vertebrobasilar Insufficiency

2.4.6 Impaired ability to speak. Dysarthria – (due to CNS disorder)

2.4.7.1 See Central Venous Thrombosis

2.4.8.1 See Vertebrobasilar Insufficiency

2.4.9.1 See Central Venous Thrombosis

2.4.10.1 See Central Venous Thrombosis

2.4.11.1 See Vertebrobasilar Insufficiency

2.4.12.1 See Central Venous Thrombosis

2.4.13.1 See Vertebrobasilar Insufficiency

2.4.14.1 See Vertebrobasilar Insufficiency

2.4.15.1 See Vertebrobasilar Insufficiency

2.4.16.1 See Vertebrobasilar Insufficiency

2.4.17.1 See Central Venous Thrombosis

2.4.19.1 See Vertebrobasilar Insufficiency

2.4.22.1 See Vertebrobasilar Insufficiency

Emerging impact of CTA/perfusion CT on acute stroke thrombolysis in a community hospital M N Brant-Zawadzki, D M Brown, L A Whitaker, W W Peck J NeuroIntervent Surg 2009;1:159-164

3.1.1 See Vertebrobasilar Insufficiency

3.2 Bruit

3.3 Calvarial (skull) mass

3.3.1 See Central Venous Thrombosis

3.4 Conjugate gaze paralysis

3.4.1 See Vertebrobasilar Insufficiency

3.5.1 See Vertebrobasilar Insufficiency

3.6 Dysarthria – impaired ability to speak due to CNS disorder

3.7 Homonymous hemianopia

3.8 Isolated cranial nerve (CN) deficit

3.9 Ophthamoplegia

3.9.1 See Vertebrobasilar Insufficiency

3.10.1 May be time sensitive, treat as expedited case

3.10.2 See Central Venous Thrombosis

4.1 Evidence of Carotid Stenosis on prior imaging

4.2 Stroke or Cerebral Infarction

5.1.1 Interval study after treatment

5.1.2 New or worsening clinical findings

5.2 Family history of at least two relatives with subarachnoid hemorrhage

MR angiography and surgery for unruptured familial intracranial aneurysms in persons with a family history of cerebral aneurysms Am. J. Roentgenol. 1999 173: 133-138

Francesca Crawley, Andrew Clifton, and Martin M. Brown Should We Screen for Familial Intracranial Aneurysm? Stroke 30: 312-316

Marieke J.H. Wermer, Gabriël J.E. Rinkel, and Jan van Gijn Repeated Screening for Intracranial Aneurysms in Familial Subarachnoid Hemorrhage Stroke 34: 2788-2791

5.4 Family history of multiple meningiomas

Stefan Graf , Alexander Schischma , Knut E. Eberhardt , Roland Istel , Birgit Stiasny , and Bernd D. Schulze Intracranial aneurysms and dolichoectasia in autosomal dominant polycystic kidney disease Nephrol. Dial. Transplant. 17: 819-823.

Chapman, AB, Rubinstein, D, Hughes, R, Stears, JC, Earnest, MP, Johnson, AM, Gabow, PA, Kaehny, WD Intracranial aneurysms in autosomal dominant polycystic kidney disease N Engl J Med 1992 327: 916-920

5.6.1 Interval Follow up

5.6.2 New or Worsening Symptoms

5.7 Preoperative study prior to carotid endarterectomy

5.8 Recent proven stroke

5.9 Subarachnoid hemorrhage

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