From the Guidelines
I recommend ordering a CT scan of the head and neck with contrast for this patient, given her history of a cervical spinal mass and recent trauma, as well as her increasing symptoms of headaches, neck pain, and dizziness. The patient's history of cervical spinal mass, which was removed, and her current symptoms suggest a possible risk for malignancy or other complications that would benefit from contrast enhancement [(1], [(1]).
Key Considerations
- The patient's symptoms of headaches, neck pain, and dizziness, which have been increasing since the fall, suggest a possible underlying condition that needs to be evaluated with imaging 1.
- The patient's history of cervical spinal mass, which was removed, increases her risk for malignancy or other complications, making contrast-enhanced CT a more appropriate choice 1, 1.
- Before ordering the CT scan with contrast, it is essential to ensure the patient has adequate renal function, no history of severe contrast allergy, and is not at high risk for contrast-induced nephropathy.
Clinical Decision-Making
The decision to order a CT scan with or without contrast depends on the clinical suspicion and the specific pathology being evaluated. In this case, the patient's history and symptoms suggest a possible risk for malignancy or other complications, making contrast-enhanced CT a more appropriate choice. However, if there were concerns about the patient's renal function or contrast allergy, a non-contrast CT or alternative imaging modalities like MRI could be considered 1.
Radiologist Consultation
In cases of uncertainty, consulting with a radiologist can help determine the most appropriate protocol based on the clinical presentation. The radiologist can provide guidance on the best imaging modality and whether contrast enhancement is necessary 1, 1.
From the Research
Patient Assessment
The patient reports a fall 6 days ago, hitting the back of her neck, with no loss of consciousness (LOC) and no head strike. She has been experiencing increasing headaches, neck pain, and dizziness, which were present prior to the fall. The patient has a history of a cervical spinal mass that was removed.
Imaging Considerations
- The patient's symptoms and history suggest the need for imaging to assess for potential cervical spine injury or other complications.
- A CT scan of the head and neck may be useful in evaluating the patient's symptoms, particularly given her history of cervical spinal mass and recent fall.
Contrast Enhancement
- The use of contrast enhancement in CT scans of the head and neck can help to differentiate between neoplastic and degenerative disease, as well as to assess vascular abnormalities 2, 3.
- However, the decision to use contrast enhancement should be based on the specific clinical scenario and the potential benefits and risks of contrast administration.
- A study suggests that 0.75 ml/kg of contrast medium may be sufficient for vascular opacification in head and neck lesions when the CT scan can be completed in about 120 s 2.
Noncontrast CT
- Noncontrast CT of the head can be useful in detecting subtle vascular changes and other abnormalities, particularly in the emergency room setting 4.
- However, dedicated vascular imaging such as CT/MR angiogram, venogram, or catheter angiogram may be necessary to confirm and characterize any suspicious abnormalities.
Recommendations
- Consider ordering a CT scan of the head and neck with contrast to evaluate the patient's symptoms and history, particularly given her history of cervical spinal mass and recent fall.
- Alternatively, a noncontrast CT scan may be considered if there are concerns about contrast administration or if the patient's symptoms suggest a need for urgent imaging.
- The decision to use contrast enhancement should be based on the specific clinical scenario and the potential benefits and risks of contrast administration, as discussed in studies 2, 3, 5.