Option 1, Status Quo

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Option 1, Status Quo

Photograph: The Role of

Acute CT & MRI in Dizziness

Kevin A. Kerber, MD, MS

Assistant Professor, Dptmt of Neurology

University of Michigan Health System


Neuro-imaging in Dizziness

• Important contributions

– Advanced understanding of dizziness

– Helps identify individual cases

• Downsides (not a perfect test):

– Cost, time, radiation, false +/-

Kerber et al. AJEM 2010


Thought experiment

• What is optimal care? What would you want for

yourself?

• What’s your goal? (what are you trying to

accomplish?)

• Do you think everyone should do same as you?

• What would happen if that occurred?

• What are the reasons you make decision?

Dogma? Legend of bad past experience?

Evidence?


Options

Option 1: Status Quo

Option 2: Pull up the Van

Option 3: Roll up our sleeves


Option 1, Status Quo

• Dominated by HCT, HCT on the rise

Kerber et al. Acad EM 2008


Option 1, Status Quo

• Dominated by HCT, HCT on the rise

• MRI, wide variation by hospitals (0.8% to

6.2%) (less efficient over time)

Kim et al. AJ EM 2011


Option 1, Status Quo

• Signs not adequate

– HCTs bad test for ischemia (sens, 35%) 1

– No increase in proportion stroke over time 2

– ED docs strong call for help 3

– Variation in utilization by hospital 4

– Still missed cases 5

1 Brazzelli et al. Cochrane Database 2009; 2 Kerber et al Acad EM 2008;

3 Eagles et al. Acad EM 2008; 4 Kim et al. Am J EM 2011; 5 Savitz et al.

Acad EM 2007


Option 2: Pull Up the Van

http://www.nytimes.com/2011/03/02/nyregion/02scan.html?_r=1&ref=nyregion


Option 2: Pull Up the Van

• Potential downsides:

– Cost ($)

– Opportunity costs

– Feasibility (time, resources)

– MRI not perfect. Sensitivity of MRI < 24hrs

for VB stroke might be as low as 80-85% 1

– 3T MRI possibly worse than 1.5T under 6 hrs 2

1 Tarnutzer et al CMAJ 2011; 2 Rosso et al. Neuro 2010


Burke et al. Ann Neuro [In Press]


Option 3: Roll up our sleeves

• Clinical Decision Support

– Canadian C-Spine Rule

– Ottawa Ankle Rules

– Pulmonary Embolism Rules

– ABCD2 TIA Rule


Important Issues

• What is goal? (outcome)

– Stroke Diagnosis,


Important Issues

• What is goal? (outcome)

– Stroke Diagnosis, (stroke of ear?)

– Functional Outcome/Future Events

• What are risk cut points

• Can the downsides of MRI be reduced?

• Steps: Develop, validate, implement & test effect

• Components must be reliable, generalizable


What to do with next patient?

• What is your goal?

• Imaging optional in low risk patients

(exam>hx)

• CT: If concern for ICH, part of tPA protocol,

or test for ischemia if onset >12hrs(?)

• MRI strongly favored for ischemia (delayed?)

• Take this opportunity to teach


A peculiar symptom

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