Download radiology cheat sheet table of contents

RADIOLOGY CHEAT SHEET TABLE OF CONTENTS
1. INCIDENTALOMA FOLLOW UP GUIDELINES ...................................................................................................... 3
ADNEXAL CYSTIC MASSES.............................................................................................................................................. 4
ADRENAL NODULES.......................................................................................................................................................... 8
CYSTIC RENAL MASSES ................................................................................................................................................... 9
THYROID NODULES......................................................................................................................................................... 12
AORTIC ANEURYSMS ...................................................................................................................................................... 18
GALLBLADDER AND BILIARY SYSTEM ................................................................................................................... 19
SOLID RENAL MASS......................................................................................................................................................... 20
LIVER MASSES / HYPODENSITIES ............................................................................................................................ 23
PANCREATIC CYSTS ........................................................................................................................................................ 26
LYMPH NODES / LYMPHADENOPATHY ................................................................................................................. 30
SPLEEN.................................................................................................................................................................................. 32
GROUND GLASS NODULES – FLEISCHNER ............................................................................................................ 33
SOLID PULMONARY NODULES – FLEISCHNER ................................................................................................... 34
2. INTRAVENOUS CONTRAST TOPICS ...................................................................................................................... 35
PREMEDICATION FOR CONTRAST ALLERGY ....................................................................................................... 36
MANAGEMENT OF CONTRAST REACTIONS ......................................................................................................... 37
HIVES ................................................................................................................................................................................ 38
DIFFUSE ERYTHEMA.................................................................................................................................................. 39
BRONCHOSPASM ......................................................................................................................................................... 40
LARYNGEAL EDEMA................................................................................................................................................... 41
HYPOTENSION (ANAPHYLACTIC OR VASOVAGAL) ................................................................................... 42
HYPERTENSIVE CRISIS ............................................................................................................................................. 43
UNRESPONSIVE / PULSELESS................................................................................................................................ 44
PULMONARY EDEMA ................................................................................................................................................. 45
SEIZURE / CONVULSION .......................................................................................................................................... 46
HYPOGLYCEMIA ........................................................................................................................................................... 47
PANIC ATTACK ............................................................................................................................................................. 48
IMPAIRED RENAL FUNCTION AND CONTRAST .................................................................................................. 49
EXTRAVASATION OF I.V. CONTRAST ....................................................................................................................... 52
3. CLASSIFICATION SCHEMES ....................................................................................................................................... 53
OPTN CRITERIA LIVER LESION .................................................................................................................................. 54
TRAUMA GRADING SCHEMS – AAST ORGAN INJURY ....................................................................................... 59
[Type text]
Return to Table of Contents
PANCREATITIS – ATLANTA CLASSIFICATION ..................................................................................................... 64
LYMPHOMA – DEUAVILLE CRITERIA AND DELTA SUV................................................................................... 67
CT COLONOGRAPHY – C-RADS ................................................................................................................................... 69
LUNG RADS.......................................................................................................................................................................... 70
PROSTATE PI-RADS – V2............................................................................................................................................... 71
[Type text]
Return to Table of Contents
1. INCIDENTALOMA FOLLOW UP GUIDELINES
[Type text]
Return to Table of Contents
ADNEXAL CYSTIC MASSES
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
ADRENAL NODULES
[Type text]
Return to Table of Contents
CYSTIC RENAL MASSES
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
THYROID NODULES
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
AORTIC ANEURYSMS
[Type text]
Return to Table of Contents
GALLBLADDER AND BILIARY SYSTEM
[Type text]
Return to Table of Contents
SOLID RENAL MASS
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
LIVER MASSES / HYPODENSITIES
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
PANCREATIC CYSTS
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
LYMPH NODES / LYMPHADENOPATHY
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
SPLEEN
[Type text]
Return to Table of Contents
GROUND GLASS NODULES – FLEISCHNER
[Type text]
Return to Table of Contents
SOLID PULMONARY NODULES – FLEISCHNER
[Type text]
Return to Table of Contents
2. INTRAVENOUS CONTRAST TOPICS
[Type text]
Return to Table of Contents
PREMEDICATION FOR CONTRAST ALLERGY
[Type text]
Return to Table of Contents
MANAGEMENT OF CONTRAST REACTIONS
[Type text]
Return to Table of Contents
HIVES
[Type text]
Return to Table of Contents
DIFFUSE ERYTHEMA
[Type text]
Return to Table of Contents
BRONCHOSPASM
[Type text]
Return to Table of Contents
LARYNGEAL EDEMA
[Type text]
Return to Table of Contents
HYPOTENSION (ANAPHYLACTIC OR VASOVAGAL)
[Type text]
Return to Table of Contents
HYPERTENSIVE CRISIS
[Type text]
Return to Table of Contents
UNRESPONSIVE / PULSELESS
[Type text]
Return to Table of Contents
PULMONARY EDEMA
[Type text]
Return to Table of Contents
SEIZURE / CONVULSION
[Type text]
Return to Table of Contents
HYPOGLYCEMIA
[Type text]
Return to Table of Contents
PANIC ATTACK
[Type text]
Return to Table of Contents
IMPAIRED RENAL FUNCTION AND CONTRAST
I. Intravenous Access
When the power injector is utilized, a 22g or larger needle/cannula 1.25” to 1.5” length is preferred
for IV contrast injection. It is advisable to obtain a good backflow of blood to test adequate
positioning of the needle in the vein. Adequate position of the cannula in the vein is checked again,
by flushing IV with 10mls of saline flush into the vein before delivering the injection of contrast.
Use of existing access routes:
1. Only power-injection rated PICC or central lines are approved for power injection.
2. Pre-existing IV lines will be flushed with 10mls of saline flush, to ensure patency,
prior to contrast injection.
3. Port-a-cath to be accessed by R.N. or Radiologist, with training. If no trained staff is
available, send patient to the Infusion Center or Cancer Center.
4. Consult Radiologist/ Radiology RN prior to using any central line catheters. If not
power rated, the injection must be hand injection.
IIa. Prevention of Nephrotoxicity with Iodinated Contrast Media
Requirements for CREATININE and Glomerular Filtration Rate (GFR) (if available) testing prior to
contrast media injections (for the purpose of reducing the chance of contrast-induced renal failure)
A. Patients >60 years of age are to have a recent (within 6 weeks) serum Creatinine prior to
contrast injection. If there has been significant interval change in the patient’s condition, a more
recent serum Creatinine should be obtained.
B. Patients <60 years of age do not require labs, UNLESS the patient has one or more of the
following:
• History of renal disease or surgery on the kidneys: Including dialysis, kidney transplant, single
kidney, kidney surgery
• Diabetes mellitus
• History of Hypertension
• Renal Cancer
• Recently (within 3 months) had chemotherapy
C. When clinical findings or history raise doubt about the patient’s current renal function, a
radiologist will order a STAT Creatinine/eGFR test which should be done prior to injecting contrast
media.
D. IODINATED CONTRAST AGENTS (Both ionic and non-ionic contrast agents): If the serum
creatinine is > 1.5 mg/dl or GFR is < 50 ml/min/1.73m2, the radiologist will be notified. If the
creatinine is > 1.5 in a diabetic patient, > 2.0 in a non-diabetic patient, or the GFR is < 30, and the
referring physician and radiologist have determined that a contrast-enhanced imaging study must
be done to obtain critical medical information, the contrast may be given after considering the
following precautions:
[Type text]
Return to Table of Contents
1. Discuss the risks, benefits, and alternatives with the patient.
2. Adequate patient hydration must be maintained (See Section E).
3. Optional treatments include the following:
a. Mucomyst (N-acetylcysteine)
• Orally, 600 mg twice daily on the day before and the day of the contrast imaging study, or b.
Bicarbonate 150 mEq in 1000 cc D5W, 3ml/kg bolus, then 1 ml/kg/hr x 6 hours.
For patients with end stage renal disease who are on chronic peritoneal dialysis, non contrast
should be considered and contrast should only be administered after discussion with the patient's
nephrologist. This conversation must be documented.
E. Adequate patient hydration is important to minimize the risk of nephrotoxicity. No patient
receiving radiographic contrast should have NPO orders unless they are being properly hydrated
with IV fluids. Patients having a CT with oral contrast should have nothing solid 4 hours prior to the
exam, but clear liquids are allowed up until the exam. If the patient cannot take adequate oral fluids,
consider adequate intravenous hydration.
F. All patients should be encouraged to drink lots of fluids for several hours after receiving contrast
material. G. Patients taking Metformin (ACTOplusmet, Avandamet, Janumet, Fortamet, Glucovance,
Glucophage, Glumetza, Riomet, Metaglip, Jentadueto, Kombiglyze, PrandiMet):
1. Patients taking Metformin should not take the medication following the procedure. The
medication should be withheld for 48 hours after the procedure and reinstated only after clearance
by the patient’s ordering doctor.
H. No other medications should be stopped for patients received radiographic contrast media.
Important, unless specifically instructed by their physician, patients should continue taking their
regular prescribed medications for diabetes (Insulin, etc), cardiac, and other medical conditions.
IIb. Use of Gadolinium Based Contrast Agents in Patients
with Renal Insufficiency or Failure
Gadolinium-based contrast agents using a standard dose (0.2 ml/kg [0.1 mmol/kg]) are very safe in
patients with normal renal function. However, Gd-based contrast agents have been implicated in
causing Nephrogenic Systemic Fibrosis (NSF). Reported cases were patients with severe renal
dysfunction (on dialysis or eGFR < 30 ml/min), and most patients received double or triple doses of
gadodiamide (Omniscan, Amersham/GE). Therefore, we have set the following guidelines for giving
Gd-based contrast agents.
Requirements for CREATININE and GFR testing prior to contrast media injections:
A. Patients >60 years of age are to have a recent (within 6 weeks) serum Creatinine and GFR prior
to contrast injection. If there has been significant interval change in the patient’s condition, a more
recent serum Creatinine and GFR should be obtained.
B. Patients <60 years of age do not require labs, UNLESS the patient has one or more of the
following:
[Type text]
Return to Table of Contents
• History of renal disease or surgery on the kidneys:
Including dialysis, kidney transplant, single kidney, kidney surgery
• Diabetes mellitus
• History of Hypertension
• Renal Cancer
• Recently (within 3 months) had chemotherapy
C. If GFR is > 30 ml/min, then gadolinium can be given. Avoid use of Omniscan, Magnevist, and
Optimark. If GFR is < 30 ml/min, DO NOT give gadolinium unless in the judgment of the radiologist,
the anticipated benefits exceed the potential risks. If both the clinician and the radiologist decide a
gadolinium enhanced study is necessary, the Gd-based contrast agent can be given with the
following precautions:
1. Discuss the risks, benefits, and alternatives with the patient.
2. Obtain signed consent from the patient. If patient is unable to give consent, follow Medical Center
policy regarding informed consent. The radiologist must write the order for Gadolinium, including
the specific agent, dose, and reason for taking the risk.
3. Dose at no more than 0.2 ml/kg (0.1 mmol/kg). Use “half” dose if adequate for the MR study.
D. Patients who are on dialysis: The clinical indications for the study should be assessed. If
gadolinium is not necessary, a non-contrast MRI should be performed, and the referring physician
should be informed about the change in the ordered exam. If gadolinium might be helpful, the
referring physician should be called to discuss the risks and benefits of giving gadolinium to the
patient. If both the clinician and radiologist deem a gadolinium enhanced study is needed, Gd can be
given with the specifications in C above. In addition, hemodialysis should be done as soon as
possible after the scan (ACR guidelines).
[Type text]
Return to Table of Contents
EXTRAVASATION OF I.V. CONTRAST
Contrast Extravasation Guidelines:
Extravasation of contrast medium is toxic to the surrounding tissues, particularly the skin, and can
produce an acute inflammatory response. Ulceration and necrosis may result and can be identified
as early as 6 hours after the injury.
1. All patients with IV contrast extravasation are to be examined by a radiologist (examination
should include a physical examination with evaluation of the extremity, presence of distal pulses,
capillary refill, sensation, and motor skills). Document the contrast agent, volume of contrast
extravasated, and location of extravasation in the radiology report. The ordering physician should
also be notified.
2. Although there is no clear consensus, treatment includes elevation of the extremity and cold or
warm compresses and observation for 20-30 minutes.
3. Plastic surgical consultation may be indicated under the direction of the radiologist. ACR, 2013
recommends an immediate surgical consult for the following: increased swelling or pain after 2-4
hrs, altered tissue perfusion as evidenced by decreased capillary refill at any time after
extravasation has occurred, change in sensation in the affected limb, and skin ulceration or
blistering.
4. For outpatients, the radiology nurse follows up with the outpatient via a phone call the next day
And subsequent days if needed based upon the patient assessment and physician orders. For
inpatients, the clinical team will resume care of the patient.
TREATMENT
The conduct after an episode of CMEV will vary according to the protocol of each radiology department,
and might include:

discontinue the contrast infusion and notify the radiologist immediately

complete the acquisition of images of the CT series

if the canula is still in place, could be possible to aspirate any residual drug, after remove the IV
canula

apply ice pack to affected area and elevate the affected extremity to reduce swelling

keep the patient under observation for at least 2 hours

at some institutions, the policy is to require plastic surgery consultation for all patients
whose extravasations involve 100 mL or more of contrast medium

make contact with the doctor requesting the examination

it is suggested to follow up the patient by the next few days until the resolution of local edema. Can
be accomplished with a phone call to evaluate the regression of the signs and symptoms

instruct the patient to notify staff if there is
o
increasing swelling or pain over time
o
blistering, ulceration, induration or other skin changes
o
altered tissue perfusion and changes in sensation
[Type text]
Return to Table of Contents
3. CLASSIFICATION SCHEMES
[Type text]
Return to Table of Contents
OPTN CRITERIA LIVER LESION
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
TRAUMA GRADING SCHEMS – AAST ORGAN INJURY
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
PANCREATITIS – ATLANTA CLASSIFICATION
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
LYMPHOMA – DEUAVILLE CRITERIA AND DELTA SUV
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
CT COLONOGRAPHY – C-RADS
EXTRACOLONIC FINDINGS
E0 : limited exam




E1 : normal exam or normal variant
E2 : clinically unimportant finding : simple liver cyst, vertebral haemangioma > no work up required
E3 : likely unimportant or incompletely characterised finding : e.g minimally complex renal cyst >
referal depends on local centre.
E4 : potentially important finding : e.g solid renal mass, abdominal aortic aneurysm 3 > communicate
to referring physician
[Type text]
Return to Table of Contents
LUNG RADS
[Type text]
Return to Table of Contents
PROSTATE PI-RADS – V2
Pi – Rads 2 –
Peripheral zone: DWI imaging, high B-Value dominates
Central Gland / Transition zone: T2W images dominate (charcoal sign)
DCE = Secondary role
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents
[Type text]
Return to Table of Contents