When are imaging differences not treated?

When Imaging Differences Do Not Require Treatment

Imaging abnormalities that do not require treatment include: residual findings after resolved inflammation without active disease features, incidental findings without clinical significance, persistent imaging abnormalities in clinically remitted disease, and structural changes at sites without current inflammation.

Crohn's Disease: Residual Changes Without Active Inflammation

When Crohn's disease shows residual findings without active inflammation on cross-sectional enterography, treatment is not indicated 1:

• Asymmetric fat deposits within the small bowel wall, residual pseudosacculation, scarring, or mild wall thickening without luminal narrowing should not be treated if there are no morphologic or signal changes reflecting active inflammation 1
• Absent T2 signal hyperintensity, absent hyperenhancement, and absent restricted diffusion indicate inactive disease that does not require therapy 1
• Reports should explicitly state "Crohn's disease with no imaging signs of active inflammation is present" to avoid misinterpretation 1
• Gastroenterologists must recognize that imaging-based active versus inactive disease does not always equate to histologically, endoscopically, or clinically active disease 1

Large Vessel Vasculitis: Persistent Imaging Abnormalities in Remission

In patients with giant cell arteritis (GCA) or Takayasu arteritis (TAK), persistent imaging findings during clinical remission do not mandate treatment changes 1:

• Imaging is not routinely recommended to evaluate vascular inflammation in patients in clinical remission 1
• The clinical significance of persistent imaging abnormalities remains unclear, and whether these should lead to treatment changes is not established 1
• Some studies show that FDG-PET uptake intensity in remission associates with relapse risk, but other studies did not confirm these findings 1
• Pre-existing vascular damage may progress independently of active inflammation, making it unclear whether new damage always indicates active disease requiring treatment 1

Psychosis: Low-Yield Neuroimaging Findings

In new onset psychosis without neurologic deficits, most imaging findings do not alter management 1:

• The yield of CT detecting pathology responsible for psychotic symptoms or leading to significant clinical management change is very low (0% to 1.5%) in patients without neurologic deficits 1
• Neuroimaging evaluation is not always required for new onset psychosis 1
• Individual risk factor assessment should guide neuroimaging decisions rather than routine imaging 1

Prostate Cancer: Equivocal Findings Without Treatment Intent

When salvage therapy is not planned, imaging findings do not require treatment 1:

• For men in whom salvage local or regional therapy is not planned or inappropriate, there is little evidence that next-generation imaging will alter treatment or prognosis 1
• Next-generation imaging should not be offered in this scenario except in clinical trials 1
• For men who are not candidates or unwilling to receive salvage therapy, additional imaging should not be offered 1

Altered Mental Status: Suspected Toxic-Metabolic Causes

In suspected medical illness or toxic-metabolic causes of altered mental status, neuroimaging findings often do not require specific treatment 1:

• Neuroimaging evaluation is not always required in suspected toxic-metabolic causes 1
• Brain MRI may be appropriate only in certain conditions known to be associated with intracranial injury 1
• Panel disagreement exists on the value of noncontrast head CT in this scenario 1

Pulmonary Embolism: Low Probability with Negative D-Dimer

When clinical probability is low and D-dimer is negative, imaging is not supported 1:

• The literature does not support the use of CTPA for evaluation of suspected PE in patients with low to intermediate probability and negative D-dimer 1
• Normal D-dimer results in hemodynamically stable patients with low or intermediate clinical likelihood exclude the need for imaging 1
• Low clinical probability assessment with negative D-dimer can safely exclude PE without imaging 1

Common Pitfalls to Avoid

• Do not interpret "residual findings" or "chronic changes" on imaging as requiring treatment without correlating with clinical and laboratory markers of active disease 1
• Avoid ordering imaging when clinical probability is sufficiently low that negative results would not change management 1
• Recognize that imaging abnormalities may persist after disease resolution and do not automatically indicate need for treatment escalation 1
• Do not assume all imaging findings in psychiatric patients require intervention without neurologic deficits 1