How should I proceed with a potentially abnormal medical image?

Approach to a Potentially Abnormal Medical Image

When you encounter a potentially abnormal medical image, the immediate priority is to correlate the imaging findings with clinical symptoms and determine if urgent intervention is needed, while ensuring proper documentation and communication of any uncertainty in interpretation. 1

Immediate Assessment Steps

Determine Clinical Context and Urgency

• Assess whether the imaging findings suggest conditions requiring urgent intervention, such as:
  • Bladder wall thickening with dilated posterior urethra in male infants (suggests posterior urethral valves requiring urgent evaluation) 2
  • Neurological symptoms with bladder wall thickening (may indicate neurogenic bladder with spinal cord involvement) 2
  • Any findings suggesting acute vascular compromise or ischemia 3

Evaluate Image Quality and Certainty

• Document any uncertainty in the interpretation of imaging findings or quality of the examination itself in your report, as this helps referring physicians interpret results in the context of divergent clinical or laboratory findings 1
• If findings are equivocal, state their nonspecific nature clearly and explain your rationale for the conclusion, avoiding vague terms like "likely" or "suspicion of" that incompletely transfer the degree of certainty 1

Next Steps Based on Findings

For Indeterminate Soft Tissue Masses

• MRI with contrast is the most appropriate next imaging study for indeterminate masses in the groin, thigh, or other soft tissue locations due to superior soft tissue contrast resolution 4
• MRI can determine the origin of a mass and distinguish benign from malignant with 91% accuracy, while assessing relationship to neurovascular structures crucial for surgical planning 4
• Contrast-enhanced MRI has significantly greater probability of detecting malignancy than CT, Doppler ultrasound, or non-contrast MRI 4

For Indeterminate Bone Lesions

• CT is optimal for demonstrating subtle matrix mineralization and cortical destruction in bone lesions, particularly for suspected osteoid osteoma or lesions with mineralized matrix 1
• MRI is generally preferred for staging bone tumors and evaluating soft tissue involvement, though some cases benefit from both modalities as they provide complementary information 1

For Indeterminate Adnexal/Pelvic Masses

• Follow-up can be performed with either serial ultrasound (for well-visualized lesions at 8-12 weeks) or MRI (for lesions not optimally visualized or showing suspicious changes) 1
• Contrast-enhanced MRI performs superiorly to both ultrasound and non-contrast MRI due to its ability to confirm presence of internal enhancing soft tissue components 1
• The incidence of malignancy in indeterminate adnexal cysts is only 3.6-10.7%, so not all require immediate advanced imaging 1

For Suspected Vascular Abnormalities

• Ultrasound with duplex Doppler should be used initially to distinguish between low-flow and fast-flow vascular malformations and verify arterial waveforms 1
• If ultrasound raises suspicion for vascular malformation, MRI/MRA is the next appropriate study to visualize the entire extent, assess for multiple lesions, and evaluate involvement of adjacent tissues 1
• Digital subtraction angiography provides excellent definition of arteriovenous malformation anatomy but is typically reserved for symptomatic patients when simultaneous treatment is being considered 1

Communication and Documentation Requirements

Report Structure

• Include differential diagnoses and their probability in your conclusion, especially if more likely than your primary consideration 1
• List any non-primary findings that could contribute to patient symptoms, even if your main diagnosis is supported 1
• Document the absence of lesions or changes at follow-up, not just positive findings 1

Recommendations for Further Workup

• If examination findings are inconclusive, suggest appropriate further imaging based on clinical context 1
• For example, if MRI shows bone marrow edema limited to mechanical load zones without definitive structural lesions, suggest CT to help depict or exclude joint surface erosion 1

Referral Recommendations

• If imaging indicates a diagnosis requiring specialist evaluation (e.g., spondyloarthritis, suspected malignancy) and a specialist did not request the imaging, recommend referral in your report 1
• This is particularly important for incidental findings on studies performed for different indications 1

Common Pitfalls to Avoid

• Do not delay treatment initiation for imaging in patients with high clinical suspicion of time-sensitive conditions (e.g., vasculitis with ischemic manifestations) 3
• Avoid interpreting bladder distension as pathological hydronephrosis, as a distended bladder can cause mild hydronephrosis in normal healthy adults 2
• Do not rely solely on high b-value diffusion-weighted images, as not all hyperintense lesions are malignant and absence of hyperintensity does not exclude cancer 1
• Recognize that abnormal results from computer-based imaging devices do not always represent disease, as criteria for normative databases vary and results must be interpreted in clinical context 1