Can a Headache During Mri Cause False Readings

J Clin Diagn Res. 2022 February; ten(2): TC21–TC25.

Evaluation of CT and MRI Findings among Patients Presented with Principal Complaint of Headache in Key India

Garjesh Singh Rai

¹ Associate Professor, Department of Radiodiagnosis, Peoples Higher of Medical Sciences and Inquiry Center, Bhopal, MP, Bharat.

Tina Rai

² Assistant Professor, Section of Pathology, Peoples Higher of Medical Sciences and Research Heart, Bhopal, MP, Republic of india.

Leena Jain

³ Assistant Professor, Department of Ear, Nose and Throat, Peoples College of Medical Sciences and Research Center, Bhopal, MP, India.

Mahendra Mohan Vyas

⁴ Assistant Professor, Department of Radiodiagnosis, Peoples College of Medical Sciences and Enquiry Center, Bhopal, MP, Bharat.

Rakesh Roshan

^v Mail Graduate Student, Department of Radiodiagnosis, Peoples Higher of Medical Sciences And Research Center, Bhopal, MP, India.

Received 2022 Sep 18; Revisions requested 2022 November 3; Accepted 2022 Dec 22.

Abstruse

Introduction

Headache is one of the most common presenting complaints in 24-hour interval to day medical practice still the secondary causes of headache are uncommon. Thus, appropriate selection of headache patient (Pt) is of import to determine those that crave neuroimaging due to likely secondary cause. Red flags and Clinical alert benchmark (CWC) act every bit a screening tool to help in identifying those who may get benefit from neuroimaging.

Aim

To evaluate the findings of computed tomography (CT) and Magnetic Resonance Imaging (MRI) amid patients presented with the chief complaint of headache and to compare the findings between ii groups of patients.

Materials and Methods

This retrospective observational study was carried out in 500 selected patients, who underwent CT or MRI scan of head in Peoples Higher of Medical Sciences and Research middle, Bhopal, MP during the period of 2 year in between January 2013 to Dec 2014.

Siemens Somatom sensation xl piece MDCT and Siemens magnetom one.5T MRI scanner were used for imaging. Five hundred patients of ten to 70 twelvemonth age were selected for the written report based on our criterions of pick.

Results

All 500 patients were divided in to two groups A and B based on presence or absence of red flag signs and CWC signs. Group A consists of 48 patients having one or more than red flag or CWC signs and group B consists of 452 patients those don't take whatsoever above signs. 29 cases (lx.4%) out of full 48 cases of group A is suffering from chronic headache as compared to 97 cases (21.5%) out of total 452 patients of grouping B is having positive findings (p-value<0.05).

Out of 500 patients, just 29 cases (five.eight%) revealed some grade of brain parenchymal pathology whereas other associated findings were seen in 97 cases e.chiliad. sinusitis in 58 (xi.half dozen%), bone related pathology in 26 (v.2%) and chronic suppurative otitis media (CSOM) in 13 (2.vi%) patients.

Decision

CT/MRI in patients without blood-red flag or CWC sign yields very low percent of clinically pregnant positive findings in neuroimaging. In the absence of these, the only reason for CT or MRI scan seems to reassure the patients and their loved ones. CT or MRI as a screening tool in these patients has limited value in term of cost effectiveness.

Keywords: CT scan, CWC, Neurological deficit, Ruby flag

Introduction

Acute or chronic headache is one of the mutual presenting complaints in patients attending the out patient's department or emergency intendance of any hospital or full general practitioner however, only about ten% of patients with recurrent headache take secondary crusade [1]. It has been contended that virtually of the patients suffering from primary headache tin be managed with primary care and no demand of neuroimaging in nearly of the cases [2].

Because some potential aetiologies of headache may be life threatening or can badly affect neurological functions and so careful cess of a patient is very important to diagnose potentially morbid simply treatable causes. Headache cause understandable business organization non just on the office of the patient just also wellness intendance professional [3]. Few serious brain pathology presents with secondary headache for case a encephalon tumour or infinite occupying lesion (SOL) is a secondary cause of headache and CT/MRI is all-time tool for the diagnosis and treatment follow up which is essential for optimal direction of secondary headache however brain tumours accounts less than 0.ane% in the lifetime prevalence as a cause of headache [4]. So many times information technology is so difficult to discriminate between primary and secondary type of headache and it presents diagnostic dilemma before clinician. Since by definition, master headache does not require any neuroimaging because no such underlying affliction procedure exists which tin be picked up by neuroimaging. Principal headache, which include migraine, tension headache and cluster headache are benign in nature. These types of headache are usually recurrent in nature and have no underlying organic disease in their root. Secondary headache is always caused by underlying organic diseases ranging from actress cranial benign condition such as sinusitis or mastoiditis to life threatening intracranial pathology like sub arachnoid haemorrhage or brain tumours. In general, clinical practice, it is well accepted that the so called ruby-red flags of headache needs search for secondary headache. Reddish flag signs and symptoms include [five]: Early morn headache, new persistent and unexplained headache in a patient aged over 50-year-erstwhile, headache associated with changes in posture or vomiting, change in personality, knowledge or conscious level, headache with seizure, new onset neurological deficit, headache precipitated by coughing, sneezing or exercise, associated with visual disturbance (papilloedema) or jaw claudication (giant jail cell arteritis), immunosuppressed or history of malignancy, atypical aureola, headache with sign and symptoms of glaucoma, headache associated with signs of systemic illness e.g. neck rigidity, rash, fever and headache subsequent to head injury.

A detailed and defended clinical history and thorough neurological and concrete examination almost always helps in deciding which headache patient needs CT or MRI scan of encephalon to find out any underlying brain pathology. At times despite the absence of red flags or CWC sign, a CT or MRI scan of encephalon is advised by clinician to allay the anxiety of the patient and relatives. If CT is advised for neuroimaging in young children and females of kid begetting age grouping, the issue of radiation dose will exist raised. CT scanners are responsible for 40% of total medical diagnostic radiation but accounts simply 4% in radiology examinations [6]. And so the utilize of CT imaging for brain has to be balanced confronting the radiations dose. Computed tomography is a highly useful tool to find out root of the problems, but no one should allow it to supplant the proper history taking and clinical examinations to make a diagnosis. Express studies have been conducted in this region so present study designed to evaluate the findings of CT and MRI amongst patients with chief complaint of headache and to compare the findings of CT and MRI between group A (having red flag or CWC sign) and Group B (no scarlet flag or CWC sign).

Materials and Methods

Written report Design

This retrospective observational study was carried out amid 500 selected patients of 10 to 70 yr historic period, who underwent CT or MRI scan of head in Peoples College of Medical Sciences and Research Eye, Bhopal, MP during the period of 2 year in betwixt Jan 2013 to December 2014. Ethical clearance was obtained from Institutional ethical commission.

Inclusion Criterion

Patient with primary complaint of headache otherwise healthy individual and having complete CT or MRI written report with good quality images.

Exclusion Benchmark

Patient of acute head injury or history of neurosurgery (Pts having VP shunt, aneurysm clips or curl).

Subjects were divided in to two groups A and B based on crimson flag and CWC sign. CT/MRI findings were evaluated for whatsoever intra and extra cranial pathology.

Statistical assay was washed using Statistical Package of Social Science (SPSS Version nineteen; Chicago Inc., USA). Information comparison was washed by applying specific statistical tests i.e. Chi-Square test to find out the statistical significance of the comparisons. Qualitative variables were compared using proportions. Significance level was stock-still at p < 0.05.

Equipment

Siemens Somatom sensations xl piece MDCT scanner and Siemens magnetom 1.5T MRI scanner.

Results

The data obtained from records of CT and MRI section of Department of Radiodiagnosis, Peoples Medical College Hospital was analysed by using SPSS program and results prepared in grade of tables and figures. This retrospective observational report is conducted amongst 500 selected patients who underwent CT or MRI scan of head from January 2013 to December 2014. Out of 500 patients 313 (62.half dozen%) were females and 187 (37.four%) were males; 327 (65.4%) patients belong to urban expanse and 173 (34.six%) belong to rural area [Table/Fig-ane]. Out of 500 patients 392 (78.4%) patients underwent for CT and 108 (21.six%) for MRI [Table/Fig-1,​ 2]. All patients were divided into ii groups; grouping A consists of cases associated with neurological aberration as indicated in red flag signs and CWC benchmark and group B consists of cases with no red flag signs and CWC sign [Table/Fig-3]. The associations between group A and B with type of headache and positive findings were established based on chi square test. A total 56 cases amid 500 cases underwent intravenous contrast administration as based on clinician'southward request or when radiologist required it for better imaging and characterization of pathology.

[Table/Fig-1]:

Demographic distribution of study subjects according to modality, Locality & Gender.

Scanning modality	Male No. (%)	Female No. (%)	Urban	Rural	Total
CT	154 (82.iv%)	238 (76.0%)	254 (77.7%)	138 (79.eight%)	392 (78.iv%)
MRI	33 (17.6%)	75 (24.0%)	73 (22.3%)	35 (twenty.2%)	108 (21.6%)
TOTAL	187	313	327	173	500
Chi Square Value	2.76		0.293
Significance p-Value	0.097 (NS)		0.589 (NS)

Distribution of case co-ordinate to modality.

[Table/Fig-three]:

Distribution of cases according to group.

Group	No. of cases	No. of positive case	Normal scan	Chi-Square Value	p-value
A	48	29 (60.4%)	19 (39.half dozen%)	34.nine	0.001(HS)
B	452	97 (21.5%)	355 (78.5%)
Full	500	126	374

The age group ranged from x years to 70 years with the mean of 33 years [Table/Fig-4]. Patients less than ten year of age is non included in the study because very few presented with sole complaint of headache and reliable history taking is difficult in this historic period group. Group A included 48 cases (9.6%) whereas 452 cases (90.four%) were included in group B [Table/Fig-3]. Approximately 75% of the patients included in the study demonstrated absolutely normal neuroimaging findings. Out of 500 patients only 29 (5.8%) showed brain parenchymal pathology while other associated findings were seen in 97 pts (19.4%) [Tabular array/Fig-5]. Out of 97 patients; sinusitis is seen in 58 cases (11.6%), os related pathology seen in 26 cases (five.two%) and CSOM seen in 13 cases (2.6%) (p-value 0.022 which is pregnant). Out of the 29 cases of brain parenchymal pathology, 6 cases had calcified granulomas, 4 cases had ring enhancing lesions, v cases had presumptive brain tumour, v cases had parenchymal bleed, iii cases had presumptive demyelination, 4 case had subarachnoid and subdural haemorrhage and 2 case had aneurysm [Tabular array/Fig-vi,​ 7,​ 8,​ 9 and ​ 10].

[Table/Fig-4]:

Distribution of cases according to age.

Sr. No.	Historic period grouping in twelvemonth	Male No. (%)	Female person No. (%)	Total No. (%)	Chi-Square Value	p-value
1	10-20	28 (5.half-dozen%)	35 (7.0%)	63 (12.6%)	4.64	0.461(NS)
2	20-30	51 (10.ii%)	94 (18.8%)	145 (29.0%)
3	30-forty	47 (ix.four%)	92 (18.4%)	139 (27.eight%)
4	xl-50	29 (5.8%)	50 (10.0%)	79 (15.eight%)
5	50-lx	15 (iii.0%)	23 (four.6%)	38 (7.6%)
half-dozen	60-70	17 (3.4%)	19 (3.eight%)	36 (seven.2%)
Full		187	313	500

Distribution of Cases Co-ordinate to CT/MRI Findings

[Table/Fig-6]:

Distribution of cases co-ordinate to disease.

Sr. No.	Diagnosis	Male person No. (%)	Female No. (%)	No. of cases	Chi-Square Value	p-Value
1	Normal	127 (34.0%)	247 (66.0%)	374	11.0	0.199 (NS)
2	Paranasal Sinusitis	22 (37.ix%)	36 (62.1%)	58
3	Bone related pathology	fifteen (57.7%)	11 (42.3%)	26
4	CSOM	five (38.5%)	8 (61.5%)	13
v	Ring enhancing lesion and calcified granuloma	4 (xl.0%)	6 (60.0%)	x
vi	Brain tumors (SOL)	two (40.0%)	iii (60.0%)	5
7	Demyelination	2 (66.vii%)	1 (33.3%)	three
8	Parenchymal, subarachnoid and subdural hemorrhage	half dozen (66.vii%)	three (33.3%)	9
ix	Aneurysm	1 (50.0%)	1 (50.0%)	ii

(a) Axial contrast enhanced MRI image of brain is showing big peripherally enhancing SOL in frontal region (arrow). (b) Centric CECT paradigm of head shows a well-defined, markedly enhancing, rounded mass lesion in frontal region most likely meningioma (arrow)

(a) Axial CT paradigm of brain shows a big acute hematoma in right basal ganglia (arrow) with intra ventricular extension (curved arrow). (b) Axial CT image of brain is showing chronic SDH in bilateral frontal and parietal regions (arrows)

(a) Centric CT image of PNS in bone window shows concentric mucosal thickening (pointer) in both maxillary sinuses due to sinusitis. (b) Axial T2 weighted MR image of PNS shows concentric mucosal thickening in bilateral ethmoid (arrows) and sphenoid sinuses (curved arrow) due to sinusitis

(a) Axial CT image of encephalon shows calcified granulomas with perilesional edema (arrow). (b) Contrast enhanced T1 weighted axial MR image is showing a ring enhancing lesion in left parietal region (arrow)

Overall the nigh prevalent pathology constitute in the study is paranasal sinusitis which is located in the maxillary sinuses in most of the cases and was coexisting with ethmoid, frontal and sphenoid sinusitis in few cases.

The findings were considered pregnant in those who presented with headache and associated with other neurological findings (Red flag sign or CWC sign). 29 cases out of 48 (60.4%) in group A as compared to 97 cases out of 452 (21.four%) in group B had positive CT or MRI findings (p-value 0.001 which is highly significant) [Table/Fig-3]. Cases referred from causality, emergency medicine and neurosurgery section yielded more positive results than cases of other departments.

Discussion

The International Headache Society has classified headache broadly into two categories, primary and secondary, primary is without any organic cause and secondary is with an established cause [7]. Primary headache includes migraine, cluster headache and tension headache. For the diagnosis of these types of headaches only clinical assessment are sufficient and no neuroimaging is considered necessary [7].

Although in general headache is ii to iii times more common in females than males [eight]. Migraine and tension headache are more common in females while cluster headache is the simply type of headache that is more than mutual in males than females (One thousand: F ratio is 4:3) [nine]. Information technology classically occurs in young to middle-anile males particularly in smokers; with a peak incidence in late 20s. Cluster headache tends to recur during a defined time interval, hence the term 'cluster' given.

Many precipitating factors are well known most notably the consumption of alcohol. In a susceptible person stress and climatic changes may be a trigger factor [10].

Diverse studies have been conducted at different parts of the globe at different time to assess the utility of CT and MR Neuroimaging techniques in patients with headache [11–13]. One such study which was conducted at Samsun, Turkey among 70 patients to investigate the incidence of intracranial pathology past CT scanning amidst adult patients who meet Clinical Warning Criteria (CWC) for secondary headaches and to determine the importance of CWC in predicting a possible lesion on CT scan [xi]. The CWC is consisting of sudden onset of headache, rise in the frequency and intensity of headache, frequently changing character of headache, no response to analgesics and headache associated with focal neurological symptoms. The results of the study revealed 64.3% of CT scans of head was absolutely normal and 35.7% Scans manifest a positive finding which probably responsible for headache. The rate of detection of positive finding was quite college among patients who meet CWC criterion [xi].

Like report was conducted at Chitwan medical college, Bhartapur-x Nepal in 2013 among 256 patients which showed that 73% of patients presenting with headache had no morphological abnormality in CT scans of brain and reported absolutely normal browse [12].

In our study out of full 500 patients, 25.2% patients were diagnosed with a probable cause of headache by CT or MRI scan and 74.8% browse show an absolutely normal scan. In our written report 60.4% cases of grouping A demonstrated an abnormality in CT or MRI scan of brain in comparison to only 21.iv% cases of group B.

Another study was conducted amongst paediatric patients at George Washington Academy Schoolhouse of Medicine, Washington DC, to evaluate the utility of CT head in the diagnosis of a crusade responsible for headache in paediatric patients seeking treatment for headache in the emergency section. The decision was that young children presenting with headache with normal neurological exam and insignificant history, CT scans seldom atomic number 82 to diagnosis or contribute to immediate management [xiii]. Clinicians should exist cautious in advising CT scan in young children to avoid the chancy radiations exposure in such a young age however MRI is a better alternative in paediatric patients if neuroimaging is essential to reach a diagnosis or to exclude some serious intracranial pathology yet cost, cooperation and claustrophobia may be a business.

MR imaging is not first line imaging technique for the evaluation of patients who presented with chronic or recurrent headache with normal neurological signs. Neither contrast study nor repeated MR imaging contributed to reach the diagnosis of chronic or Recurrent Headache. A study was conducted at Gunma University Hospital of Nippon, to evaluate the efficacy of MRI in the diagnosis of an abnormality in patients who presented with chronic or recurrent headache without any neurological deficit. Out of a total of 306 patients, 169 pts (55.2%) had no abnormality in the scan, 135 pts (44.1%) had a small associated abnormality while simply two pts (0.seven%) take intracranial pathology which may be culprit of headache [14].

Many such studies have been conducted previously at different institutions and issue have shown the results that CT is modality of low yield in patients who investigated for chronic headache without any neurological aberration [fifteen]. Although the majority of patients who present with chronic or recurrent headache in OPD of any full general practitioner or infirmary without whatever neurological arrears, many of them employ to undergo neuroimaging with CT or MR imaging to exclude any serious intracranial pathology [4,16]. Thus our effort should exist to reduce the hazardous radiation exposure before advising CT for headache, as CT scan involves considerable radiation dose.

Maximum cases of our study vest to reproductive age group. Unnecessary CT scan exposes the patient to radiation and its side result in this vulnerable historic period group. Because the yield of CT or MRI scans in group A is very meaning in comparison to the group B, use of CT /MRI scans must be ethical and selective particularly in patients of grouping B because the toll and radiation exposure. Neuroimaging is mandatory for the patients suffering from 1 or more reddish flag or CWC signs every bit mentioned above. The associated findings like paranasal sinusitis, calcified granulomas, mild DNS, CSOM and mastoiditis may exist incidental findings and falsely increasing the yield of CT.

A patient presented after few episodes of severe headache may harbour considerable anxiety and fear of encephalon tumour or many other serious diseases which non merely badly impact person's behaviour, psychology and fifty-fifty economical benefit in terms of productivity from their job. The assessment of value for loss is inherently very subjective and hard to measure. So 1 practically possible style to do so would exist but ask the patient or relatives how much they would be willing to pay for neuroimaging which would diagnose or exclude pregnant pathology of brain [17–21].

Weingarten et al., in their study showed that a headache associated with brain tumour may be non-specific and then many times cannot be reliably differentiated from other more than common benign causes of headache strictly on clinical grounds so in those cases neuroimaging play an important role to include or exclude the possible crusade [22]. Presence of white matter affliction is mostly circumstantial with chronic hypertension and aging procedure in well-nigh of the cases [23,24] merely it may not exist primary crusade of headache.

Women endure 2 to three times more from primary headache especially migraine than males; this has been proved again in our study. This could exist due to hormonal factors. The link between migraine and female person sex activity hormone is well established. Migraine has strong correlation with menstrual wheel, pregnancy, OCP, menopause and HRT [25]. It has been observed in our study that person either male or female person belongs to urban area is more prone to main headache. The reasons responsible for it may be insufficiently stressful urban life, racket and air pollution, long hours of driving or transportation, excessive use of electronic devices e.g. mobile phone, tv set, figurer and lack of healthy physical activity which leads to cervical spondylosis and referred headache. Due to better availability of health care and diagnostics facilities in cities and awareness for early treatment; positive detection rate is quite high in urban population while in general, rural population seeks treatment for headache in later stage due to socio-economical causes [26–28].

Our data analysis & results ostend the impression that conscientious history taking and thorough physical examination is sufficient to exclude major intracranial pathologies and information technology is toll-effective means for evaluating headache patients with non-focal neurological examinations. CT and MRI both are not suitable as a screening tool and should be reserved for those patients in whom there is a high clinical suspicion of some serious intracranial pathology.

Paranasal Sinus disease is certainly associated with headache in so many cases. MRI and CT are more sensitive for inflammatory changes in the sinuses than plain Ten-ray only the clinical significance and cost effectiveness of such type of MRI or CT scan is debatable. We have not separated acute and chronic headache in our study because we are primarily interested in determining the impact of CT/MRI on the direction of patients presenting with the sole symptom of headache whether information technology was acute or chronic.

Determination

CT/MRI of patients with not-focal headache yields a low percentage of clinically significant positive findings in neuroimaging. The toll-effectiveness of MRI or CT as a screening tool in these patients is having express value. Neuroimaging of encephalon is rarely helpful in the diagnosis of headache if it is not associated with other symptoms and /or signs of an intracranial pathology. The reasons for imaging of headache are complex; however, information technology includes potential psychosocial benefits of a negative exam to patient, fear of litigation on treating dr. and doubts most the sensitivity of the concrete examination. Patients with red flag sign or who meets with clinical alarm criteria of secondary headache must undergo for neuroimaging by CT or MRI. In the absence of these, the but reason for CT or MRI scan seems to be reassuring the patients and their loved ones that 'nothing to worry' and 'take the medicine and you will be cured'.

Notes

Financial or Other Competing Interests

None.

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