Revised Atlanta Classification

MRI Brain Scheme for Expanded Protocols 2012

MRI

BRAIN – ADULT

ROUTINE

HEADACHE

HEADACHE WITH VISUAL PROBLEMS

HEADACHE WITH VERTIGO

HEADACHE WITH VOMITING

HEADACHE – MIGRAINE

HEADACHE – EAR PAIN

HEAD ACHE – NECK PAIN

HEADCAHE – SYNCOPE

HEADACHE – SEIZURE

HEADACHE – CRANIAL NERVE PALSY

HEADACHE – INFARCT

HEADACHE – DEMENTIA

HEADACHE – VASCULITIS

SEIZURE

CHRONIC SEIZURE

CHILDHOOD SEIZURE

ACUTE ONSET SEIZURE

SUBACUTE (<3 WEEKS) ONSET

OLD HISTORY OF SEIZURE

SINGLE EPISODE OF SEIZURE IN PAST

MULTIPLE EPISODES IN PAST

EPILEPTIC PATIENT ON REGULAR TREATMENT

EPILEPTIC PATIENT ON IRREGULAR TREATMENT

SEIZURE WITH CRANIAL NERVE PALSY

SEIZURE WITH INFARCT

VERTIGO

SINGLE ACUTE EPISODE OF VERTIGO

MULTIPLE ACUTE OR SUBACUTE EVENTS

VERTIGO WITH SENSORY NEURAL DEAFNESS

VERTIGO  WITH HEADACHE

VERTIGO WITH CRANIAL NERVE PALSY

VERTIGO WITH  FOCAL NEUROLOGICAL DEFICIT

VERTIGO ?SYNCOPE  - SINGLE SEVERE ACUTE EVENT

VERTIGO ?SYNCOPE  - MULIPLE  EPISODES

CEREBRO-VASCULAR DISEASE

ACUTE INFARCT

HYPERACUTE STROKE

EARLY SUBACUTE INFARCT

LATE SUBACUTE INFARCT

CHRONIC INFARCT

LACUNAR INFARCT

MULTIPLE LACUNAR INFARCTS

EMBOLIC INFARCTS

HEMORRHAGIC INFARCT

INFARCT WITH HEMORRHAGE

HEMORRHAGE WITH INFARCT

TIA

LARGE INFARCT

MULTIPLE LARGE INFARCTS

MULTIPLE SMALL INFARCTS

CORTICAL INFARCT

SUBCORTICAL INFARCT

BRAINSTEM INFARCT

THALAMIC INFARCT

VASCULITIS WITH INFARCT

MIGRAINE WITH INFARCT

MENINGITIS WITH INFARCT

VENOUS INFARCT

INFARCT WITH SAH

SAH WITH INFARCT

HEMORRHAGIC INFARCT WITH VENTRICULAR BLEED

VENOUS THROMBOSIS WITH INFARCT

EMBOLISM WITH HEMORRHAGIC INFARCT

ACUTE ICA OCCLUSION WITH INFARCT

CHRONIC ICA OCCLUSION WITH INFARCT

BILATERAL CHRONIC ICA OCCLUSION

MCA INFARCT

ACA INFARCT

PCA INFARCT

BASILAR TRUNK INFARCT

VERTEBRAL ARTERY INFARCT

PICA INFARCT

AICA INFARCT

SCA INFARCT

ANTIPHOSPHLIPID ANTIBODY SYNDROME

HYPERHOMOCYSTENEMIA

BINSWANGERS DISEASE

LEUKARIOSIS

CEREBRAL AMYLOID ANGIOPATHY

ENCEPHALOPATHY

HEPATIC ENCEPHALOPATHY

METABOLIC ENCEPHALOPATHY

UREMIC  ENCEPHALOPATHY

DIABETIC KETOSIS ENCEPHALOPATHY

HIV ENCEPHALOPATHY

HYPOXIC- ISCHEMIC ENCEPHALOPATHY

TOXIC ENCEPHALOPATHY

MITOCHONDRIAL ENCEPHALOPATHY

PML

DEMENTIA

ALZHEIMERS DISEASE

NPH

VASCULAR DEMENTIA

FRONTO-TEMPORAL DEMENTIA

PICKS DEMENTIA

CADASIL

COMBINED DEMENTIA

ACUTE DEMETIA

SUBACUTE DEMENTIA

ETHANOL RELATED DEMENTIA

DRUG INDUCED DEMENTIA

PARKINSON WITH DEMENTIA

POST TRAUMATIC DEMENTIA

BRAIN TUMOR DEMENTIA

DIALYSIS DEMENTIA

NEURODEGENERATIVE DISEASES

PARKINSONISM

MSA

PSP

HUNTIGNTONS DISEASE

PANTOTHENATE KINASE-ASSOCIATED NEURODEGENERATION

CEREBELLAR ATROPHY

LEUKODYSTROPHIES

CORTICOBASAL DEGENERATION

WILSONS DISEASE

           

SSPE

PARANEOPLASTIC SYNDROME

ENCEPHALITIS

HSV ENCEPHALITIS

JAPANESE ENCEPHALITIS

DENGUE ENCEPHALITIS

LEPTOSPIRA ENCEPHALITIS

HEMORRHAGIC VIRAL ENCEPHALITIS

MENINGO-ENCEPHALITIS

HIV ENCEPHALITIS

TOXOPLASMA ENCEPHALITIS

AMEBIC ENCEPHALITIS

RASMUSSEN ENCEPHALITIS

CJD

MENINGITIS

SUSPECTED MENINGITIS

PROVED MENINGITIS

TREATED MENINGITIS

MENINGITIS WITH SUBDURAL COLLECTION

MENINGITIS WITH EPIDURAL COLLECTION

MENIGITIS WITH VENTRICULITIS

MENINGITIS WITH VASCULITIS

MENINGO-ENCEPHALITIS

MENINGITIS WITH CRANIAL NERVE PALSY

MENINGITIS WITH OPTIC NEURITIS

DEMYELINATION

ADEM

ADEM WITH TRANSVERSE MYELITIS

ACUTE DEMYELINATION

SUBACUTE DEMYELINATION

BRAINSTEM DEMYELINATION

ACUTE MS

SUBACUTE MS

CHRONIC MS

MS WITH OPTIC NEURITIS

DEVIC DISEASE

MS WITH DEMENTIA

OPTIC NEURITIS

ISOLATED CRANIAL NERVE DEMYELINATION

THIRD NERVE PALSY

FOURTH NERVE PALSY

SIXTH NERVE PALSY

SEVENTH NERVE PALSY

EIGHT NERVE PALSY

NINTH NERVE PALSY

TENTH NERVE PALSY

ELEVENTH NERVE PALSY

TWELTH NERVE PALSY

HYDROCEPHALUS

OBSTRUCTIVE HYDROCEPHALUS

NON-COMMUNICATING HYDROCEPHALUS

EXTRAVENTRICULAR OBSTRUCTION

NPH

INTRACRANIAL MASS LESION

NEOPLASTIC

MENINGIOMA

CONVEXITY

CP ANGLE

PARA SELLAR

PETROUS TEMPORAL

SPHENOID WING

ORBITAL APEX

POSTERIOR FOSSA

FORAMEN MAGNUM

INTRAVENTRICULAR

GLIOMA

SUPRATENTORIAL

GANGLIO-CAPSULAR REGION

THALAMIC

BRAINSTEM

PONTINE

TECTAL

MEDULLARY

CEREBELLAR

VERMIS

INTRAVENTRICULAR

HYPOTHALAMIC

HYPOTHALAMO-CHIASMATIC

HIPPOCAMPAL

MEDIAL TEMPORAL

OPTIC NERVE

GLIOMATOSIS CEREBRI

EPENDYMOMA

DNET

OTHER NEOPLASTIC

SCHWANNOMA

NEUROFIBROMA

METASTASES

LYMPHOMA

CONGENITAL

DERMOID

EPIDERMOID

ARACHNOID CYST

LIPOMA

NEURENTERIC CYST

RADIATION NECROSIS

POST SURGICAL  

IMMEDIATE

RECENT

LONG TERM FOLLOW UP

INFECTIVE SOL

GRANULOMA

TUBERCULOMA

NEUROCYSTICERCOSIS

HYDATID

ABSCESS

PYOGENIC ABSCESS

TUBERCULAR ABCESS

FUNGAL ABSCESS

OTHER PARASITIC ABSCESS

TRAUMA

TRAUMATIC BRAIN INJURY

CONCUSSION

CONTUSION

IC BLEED

INTRAVENTRICULAR BLEED

EDH

SDH

SAH

VASCULAR

ANEURYSM

CICLE OF WILLIS ANEURYSM

VERTEBRO-BASILAR ANEURYSM

PARASELLAR ANEURYSM

ANEURYSM WITH OCULAR PALSY

ANEURYSM WITH OTHER CRANIAL NERVE

MULTIPLE ANEURYSMS

AVM

CAROTICO-CAVERNOUS FISTULA

DURAL AVM

DURAL AVF

CAVERNOMA

DEVELOPMENTAL VENOUS ANOMALY

MIXED MALFORMATIONS

STURGE-WEBER

ARTERIAL THROMBOSIS

DISSECTION

TUMOR WITH VASCULAR ENCASEMENT

TUMOR WITH ANEURYSM

ANEURYSM WITH ACTIVE BLEED

ANEURYSM WITH HEMATOMA

ANEURYSM WITH SAH

ANEURYSM WITH IVH

VERTEBRAL ARTERY DISSECTION

BASILAR DISSECTION

Tumor Markers in Liver lesions

Ask whether AFP , CEA  done in all cases of liver MRI studies  

SWI in CVT

Do SWI sequences for all Cerebral angio and veno cases

Please do it even when only angio or Veno is only asked if time permits . The sagittal T1WI can be avoided

It helps us detect lesions faster

MRI PROTOCOLS 2012 Special instructions

MRI PROTOCOLS 2012

Special  instructions

1.    Perianal fistula – Please fill up the Questionnaire 

             

Identify the external opening of fistula tracks in the anal clock diagram  . The positions should be identified with patient in supine position only .

Thin FSET2WI  sections to be taken perpendicular  to the long axis of anal canal lumen .

Injection of contrast through fistula tracks in selected cases only .

If abscess or supralevator extension or extension into pelvic cavity , pelvic side wall , gluteal muscles  IV contrast may be given.

2.    MR Perfusion

Use cannula or butterfly with 20G or 18G so that 10ml of the Gd contrast can be pushed within 2 seconds .

Ensure good  flow with a pre-injection using saline .

Saline flush to be used in all cases of MR Contrast administration

      3. MRI Liver

         

          Use only Multihance as MR Contrast

         

          Do Dual echo , GRE ,DWI ,SE sequences only after instruction to do .For routine cases these sequences are not needed

4. MRI Kidneys – The artifacts in left kidney to be taken care of . Do dual echo post contrast

5. AVN Hip  -  Take Digital X -ray of both hip

6. Parasellar lesions , orbital apex lesions  : Post contrast FIESTA . If vessel encasement or involvement seen do post contrast angio sequence also .    Take CT sections if bone erosion or sclerosis suspected .

7. Neurocysticercosis – Do FIESTA after contrast media administration .

8. Tuberculoma – Do MR perfusion , Single voxel spectroscopy .

9. MR Peripheral angiography with contrast – Do post contrast T1WI in select cases only .

10. Use Dotarem as IV  contrast in cases with  borderline renal failure . Gd can be given upto cretainne 4mg% . More than 2mg% carries risk . To have informed consent .Also inform clinician .

11. MRI Prostate and Uterus for endometrial carcinoma – DWI and ADC map to be done 

12. MRI uterus – Do imaging in the plane of endometrium also .Axial and coronal T2  images

13.MRI Prostate – Imaging to be done in the axis of the gland.

PEDIATRIC SEDATIONS

TABLE – I

Chloral Hydrate in Pediatric sedation

1. Method of Administration.

20 to 75 mg / kg orally or rectally (maximum single dose, 1.0g; if a second dose in given, the maximum total dose in either 100 mg / kg or 2.0 g, whichever is lower).

2. Contraindications
1. Compromised hepatic function.
2. History of obstructive sleep apnea*
3. Previous unfavorable experience with chloral hydrate.
3. Advantages

No specific advantages for sedation and treatment of children with fractures.

 

4. Disadvantages
1. Prolonged time to peak effect (as long as 60 min).
2. Difficult to titrate.
3. Prolonged observation period required.

* Caution is required when using any sedative medication in patients with obstructive sleep apnea.

TABLE – II

Benzidiazepines in Pediatric Sedation

1. Method of Administration.
1. Diazepam: 0.1 to 0.3 mg / kg IV or PO. IM administration should be avoided because it is painful.
2. Midazolam

1.      PO: 0.5 – 0.75 mg / kg.

2.      Nasal: 0.3 – 0.4 mg / kg*

3.      IM: 0.03 – 0.1 mg / kg.

4.      IV: 0.05 – 0.1 mg / kg.

2. Contraindications
1. Previous unfavorable experience with benzodiazepines.
2. (?) Early pregnancy (possible teratogenicity).
3. Altered state of consciousness.
3. Advantages
1. Generally provide excellent sedation and amnesia.

                  B. Reversible if necessary (flumazenil, 10 mg / kg, upto a total dose of 1.0 mg.

4. Disadvantages
1. No analgesic effect.
2. Respiratory depression, especially with parenteral administration.
3. Combination with narcotics may lead to oversadation or respiratory arrest.

* Many children find the intranasal administration of midazolam to be very unpleasant. This    

    method of administering midazolam is not recommended.

TABLE – III

Opioids in Pediatric Sedation

1. Method of Administration.
1. Morphine: 0.05 – 0.1 mg / kg IM or IV.
2. Meperidine: 0.5 – 1.0 mg / kg IM or IV.
3. Fentanyl: In increments of 0.001 mg / kg IV (maximum total dose, 0.004 – 0.005 mg / kg).
4. Nalbuphine: 0.1 mg / kg IM or IV.

    

      Patients younger than 3 months old should be given no more than half of these doses initially. IV titration to desired effect is the ideal way to administer all Sedative medications.

2. Contraindications
1. Altered state of consciousness.
2. Previous unfavorable experience (excludes that medication only).
3. Sedation for non painful procedure.
3. Advantages
1. Provide excellent analgesia.
2. Reversible if necessary (naloxone 0.001 – 0.005 mg / kg IV titrated to effect).
4. Disadvantages
1. Risk of respiratory depression and apnea.
2. Increased risk of respiratory depression and apnea when combined with other sedatives.
3. No amnestic effects.
5. Additional side effects (more likely when used in recurrent doses for treatment of pain).

Nausea, vomiting, pruritus, constipation, decreased gastric motility.

TABLE – IV

Fentanyl and Midazolam in Pediatric Sedation*

1. Method of Administration IV titration to effect.
1. Midazolam: In increments of 0.05 mg / kg to a maximum of 0.1 mg / kg. Wait 5 min between doses.
2. Fentanyl: Begin 5 min after last midazolam dose. Give in increments of 0.001 mg / kg to a maximum of 0.003 mg / kg, wait 2 to 3 min between doses.
2. Contrandications
1. Altered state of consciousness.
2. Previous unfavorable experience with either medication.
3. Specific contraindications to benzodiazepines or opioids (seen Tables 2 and 3).
3. Advantages
1. Provides sedation, amnesia (midazolam), and analgesia (fentanyl).
2. Reversible if necessary (see Tables 2 and 3).
4. Disadvantages
1. Additive respiratory depressant effects.
2. Additive depressant effects on protective airway reflexes with increased risk for regurgitation and aspiration of gastric contents.

* An excellent review of the advantages and problems associated with this drug regimen is provided in Yaster M, Nichols DG, Deshpande JK, Wetzel RC.

Miazolam – fentanyl intravenous sedation in children: case report of respiratory arrest. Pediatrics 1990;86:463-467.

TABLE – V

Ketamine in Pediatric Sedation

1.       Method of Administration and Dosage.

A.     IM: 4 mg / kg.

B.     IV: 1 – 2 mg / kg.

C.     PO: 6 – 10 mg / kg.

D.     Rectal: 5 – 10 mg / kg.

2.       Contraindications

A.     Altered state of consciousness.

B.     Increased intracranial pressure.

C.     Active upper respiratory infections (increased quantity of secretions and possible increased risk of laryngospasm).

D.     Full stomach.

E.      Prior unfavorable experience with ketamine.

F.      Patients older than 16 yrs old (increased incidence of emergence phenomena).

3.       Advantages

A.     Provides Sedation, amnesia, intense analgesia.

B.     Sympathetic-mediated activity may be beneficial for children with asthma.

4.       Disadvantages

A.     Increases production of saliva and tracheobronchial secretions; coadministration of glycopyrrolate 0.01 mg / kg recommended.

B.     Potential for loss of the airway from:

1.      Laryngospasm secondary to increased secretions.

2.      Aspiration from laryngeal incompetence.

3.      Apnea.

C.     Emergence phenomena: Rare in young children. No advantage to quiet  

      environment. Midazolam may help, but may contribute to oversedation.  

TABLE – VI

Dosing Schedules and Formulations for Nonsteroidal Anti-inflammatory Drugs in children.

Agent	Dose	Formulations*
Ibuprofen (oral)	5 -10 mg / kg q6h (pubilished dose is for treatment of fever, not specifically for analgesia).	100 mg / 5 mL suspension Tablets: 200, 300, 400, 600, 800 mg.
Naproxen (oral)	5 – 7.5 mg / kg q12h	125 mg / 5 mL suspension Tablets: 250, 375, 500 mg.
Ketorolac (IM, IV)	0.5 mg / kg q6h	Injectable 30 mg / mL.
Choline Magnesium	50 mg / kg / day	500 mg salicylate / 5 mL solution
Trisalicylate (Trilisate) (oral) @	Divided into 2 or 3 doses (maximum daily dose, 2.25 g)	Tablets: 500, 750, 1000 mg.
Salsalate @ (oral) (Disalcid)	Pediatric dose not published; adult maintenance dose is 2 – 4 g / day.	Tablets: 500, 750 mg.
Acetaminophen $ (oral, rectal)	10 – 15 mg / kg q4 – 6h	80 mg / 0.8 mL drops 80 mg chewable tablets 160 mg / 5 mL solution 325-, 500-mg tablets 120-, 325-, 650-mg suppositories
* An exhaustive listing of available formulations for NSAIDs may be found in AHFS     Drug information 1994. @ Although they are salicylates, choline magnesium trisalicylate, and salsalate do not cross-react with aspirin and may be used in patients allergic to aspirin. As many as 28% of children with asthma may be in this group of patients. Owing to an association with Reye syndrome, salicylates should be avoided in children with flu-like symptoms or chickenpox. $ Acetaminophen is considered a member of this class of medications, even though it mainly acts centrally and it only very weaknly inhibits prostaglandin synthesis. Acetaminophen also does not cross-react with aspirin and may be used in patients allergic to aspirin. Adapted from Nonsteroidal Anti-inflammatory agents. In McEvoy GK, Litvak K, Welsh OH Jr, eds. AHFS Drug Information 1994. Bethesda, MD: American society of Hospital Pharmacists, 1994; Walson PD, Mortensen ME. Pharmacokinetics of common analgesics, anti-inflammatories, and antipyretics in children. Clin Pharmacokinet 1989;17:116-137, with permission.