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physical examination. Endometrial carcinoma is the most common gynecologic cancer in the United States, with a mean age of 60 years at diagnosis . Although 20% of cases are diagnosed in premenopausal women , most patients are postmenopausal. Th
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3Panel Chair, University of Texas MD Anderson Cancer Center, Houston, Texas. 4Indiana. University ... 10Henry Ford Health System, Detroit, Michigan. 11Memorial Sloan ... 13Cleveland Clinic Foundation, Cleveland, Ohio. The American ...
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ACR Appropriateness CriteriaÂ®. 1. Nontraumatic Aortic Disease. American College of Radiology. ACR Appropriateness CriteriaÂ®. Clinical Condition: Nontraumatic Aortic Disease. Radiologic Procedure. Rating. Comments. RRL*. X-ray chest. 9. â¢. CT ches
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13The Robert H. Lurie Comprehensive Cancer Center of Northwestern .... Loft A, Berthelsen AK, Roed H, et al. ..... Dose of Brachytherapy (Cumulative Point A.
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Date of origin: 1995 Last review date: 2008
American College of Radiology ACR Appropriateness Criteria® Clinical Condition:
Suspected Upper-Extremity Deep Vein Thrombosis
US upper extremity(ies) with Doppler
MRA chest (noncoronary) without and with contrast
Venography upper extremity(ies) and SVC
CTA chest (noncoronary)
Radionuclide venography upper extremity(ies) and chest
Comments Standard for arm veins. Other modalities required for evaluating central veins. Simple, low cost evaluation of lines, mediastinal contours, and cervical ribs. Asymptomatic side injection preferred. For central veins. See statement regarding contrast in text under “Anticipated Exceptions.” Although the gold standard, generally reserved for inconclusive noninvasive studies. Asymptomatic side injection preferred. Alternative to MRA for central veins. Largely supplanted. Limited use for central veins when CTA and MRA are both contraindicated.
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
☢☢☢ ☢☢☢ ☢☢☢ *Relative Radiation Level
Suspected Upper-Extremity DVT
SUSPECTED UPPER-EXTREMITY DEEP VEIN THROMBOSIS Expert Panel on Vascular Imaging: E. Kent Yucel, MD 1 ; Jorge D. Oldan, MD2; Frank J. Rybicki, MD, PhD3; Richard A. Baum, MD4; W. Dennis Foley, MD5; Michael R. Jaff, DO6; Scott A. Koss, MD7; Leena Mammen, MD8; M. Ashraf Mansour, MD9; Vamsidhar R. Narra, MD.10
increases the likelihood of venous thrombosis by altering flow , causing damage to the endothelial lining of the vein, and serving as a site for platelet adherence . The increased use of chronically indwelling catheters for hemodialysis, chemotherapy, or parenteral nutrition, often in a population that already has additional risk factors for venous thrombosis, has increased the incidence of upperextremity DVT. As is the case with lower-extremity DVT, the likelihood of upper-extremity DVT increases with the presence of risk factors such as age, previous thrombophlebitis, postoperative state, hypercoagulability [3,4,8], heart failure , cancer [4-8,11,13], right heart procedures, and ICU admissions .
Summary of Literature Review Introduction/Background Upper-extremity venous thrombosis often presents as unilateral arm swelling. The differential diagnosis includes a mass lesion or other lesion compressing the veins and causing a functional venous obstruction, venous stenosis, or an infection causing edema . Bilateral upper-extremity swelling may also be due to right-sided heart failure, although this is typically associated with generalized swelling, in contrast to central vein obstruction, which can cause swelling limited to the upper extremity and face .
The location of the venous thrombosis is strongly linked to the clinical presentation. For example, head, neck, and bilateral upper-extremity swelling suggest a central process in the mediastinum  involving the superior vena cava or both subclavian and brachiocephalic systems . Superficial thrombophlebitis is associated with local pain, induration, and, often, a palpable cord. It is rarely, if ever, associated with diffuse arm swelling . Unilateral swelling indicates an obstructive process at the level of the brachiocephalic, subclavian, or axillary veins [14,15]. DVT limited to the brachial veins need not be associated with swelling. Isolated jugular vein thrombosis is asymptomatic and rarely causes swelling. There may be a correlation between upper-extremity and lower-extremity DVT, and investigation of the lower extremities as well should be considered if an upper-extremity thrombus is found in the absence of a local cause .
Obstruction of previously functioning lymphatics or the absence of sufficient lymphatic channels to ensure effective drainage may also cause arm swelling. Lymphatic obstruction can be seen with infection such as cellulitis or can be secondary to invasion of the lymphatics by tumor. Absence of the lymphatics can be congenital or secondary to surgery, such as following a radical mastectomy . The following recommendations are made with the understanding that venous disease, specifically venous thrombosis, is the primary diagnosis to be excluded or confirmed in a patient presenting with unilateral upperextremity swelling.
Differentiating Causes of Upper-Extremity Swelling The initial approach to a patient who presents with a swollen upper extremity is exclusion of venous thrombosis because anticoagulation is typically required and the underlying lesion may require a more aggressive intervention such as thrombolysis. Once the diagnosis of DVT is excluded, other etiologies may need to be evaluated. Different imaging techniques that can be used to achieve the diagnosis include noninvasive tests such as radionuclide venography, ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), and finally venography.
Upper-Extremity Deep Vein Thrombosis Upper-extremity deep vein thrombosis (DVT) can be associated with indwelling catheters [3-7], be idiopathic or posttraumatic [5,8], or be secondary to extrinsic compression syndrome ( “effort thrombosis” or PagetSchrötter disease) [5,9]. Upper-extremity DVT is commonly associated with the presence of indwelling central venous catheters [3,6,7,1012]. The presence of the catheter, a foreign body,
Chest Radiography Because of the broad differential diagnoses of upperextremity swelling, a chest radiograph may identify a mass lesion responsible for central venous obstruction or help confirm the presence and location of wires, catheters, or a retained wire or catheter fragment. Rare osseous entities that might be associated with extrinsic compression syndromes, such as a cervical rib, would also be detected.
Principal Author and Panel Chair, Tufts Medical Center, Boston, Massachusetts. 2 Research Author, Tufts Medical Center, Boston, Massachusetts. 3 Panel Vice-chair, Brigham and Women’s Hospital, Boston, Massachusetts. 4 Brigham and Women’s Hospital, Boston, Massachusetts. 5 Froedtert Hospital East, Milwaukee, Wisconsin. 6 Massachusetts General Hospital, Boston, Massachusetts, American College of Cardiology. 7 Radiology Waukesha, Waukesha, Wisconsin. 8 Advanced Radiology Services, Grand Rapids, Michigan. 9 Vascular Associates, Grand Rapids, Michigan, Society of Vascular Surgeons. 10 Mallinckrodt Institute of Radiology, Saint Louis, Missouri. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply society endorsement of the final document. Reprint requests to: Department of Quality & Safety, American College of Radiology, 1891 Preston White Drive, Reston, VA 20191-4397.
ACR Appropriateness Criteria®
Radionuclide Imaging, Flow Studies Radionuclide studies can confirm upper-extremity venous obstruction. The diagnostic criteria include failure to visualize one or more of the main venous segments 2
Suspected Upper-Extremity DVT
(axillary, subclavian, brachiocephalic, or superior vena cava) and visualization of collateral venous channels. This test is typically not able to differentiate intrinsic venous thrombosis from extrinsic compression [2,17-19].
abnormalities are seen, conventional venography may be necessary . Gray-scale imaging can be used to identify echogenic thrombus. However, acute hypoechoic thrombi may be missed using gray-scale imaging alone. Adjunctive use of color flow images can help in confirming the presence or absence of hypoechoic thrombus. Correlative studies between ultrasound and venography show diagnostic sensitivities and specificities above 80% [5,8,10,12,2022,25,27-29].
X-ray Venography This is the “reference standard”  examination for evaluating the upper-extremity veins. The examination carries the risks associated with the injection of an iodinated contrast agent [20,21]. Patient tolerance has been improved, and the risks of adverse events have been reduced with low-osmolar contrast agents. Direct evidence of venous thrombus is based on the visualization of a filling defect in the vein or of an abrupt occlusion, usually with the presence of collateral channels . Venography can identify fixed venous stenoses and, with upper-extremity maneuvers (abduction), can identify extrinsic venous compression. Asymptomatic or minimally symptomatic venous compression with arm abduction should be treated with caution, as this finding can be made in a substantial number of normal individuals. Despite its widespread acceptance as a reference standard based on extension of evidence associated with lower-extremity DVT, there are limited clinical trials supporting its use.
Magnetic Resonance Imaging Approaches to venous imaging using MRI include blackblood and flow-based or contrast-enhanced bright-blood techniques . Black-blood techniques include conventional T1 or T2 spin-echo [24,31] or fast spin-echo imaging. However, the black blood effect on routine spinecho imaging may not be consistent, and newer double inversion-recovery techniques provide more reliable black blood imaging . Using black-blood imaging, the presence of thrombus is inferred from focal high signal, often with enlargement, of the involved vein, but it must be differentiated from a variety of flow artifacts . Flow-based bright-blood MR venography (MRV) techniques include time-of-flight (TOF) [30,32,33] and phase contrast [30,31]. For venous imaging, TOF is limited to a 2D implementation due to signal saturation of slow flow . Vessels with primarily in-plane flow are more difficult to image due to saturation ; 2D TOF is thus most useful in the axial plane to image flow in the jugular veins, right brachiocephalic vein, and superior vena cava (SVC) which are oriented primarily in the superior-inferior direction. TOF venography can be used to image the subclavian vein, but more time-consuming sagittal acquisitions are preferred due to the direction of flow, and breathing artifacts may also impair imaging quality [4,34]. Phase contrast has not been widely used for upper-extremity venography due to the slow flows that must be detected . Recently, balanced gradient echo (steady-state free precession), and cardiac-gated 3D fast spin-echo techniques have been implemented for noncontrast MR vessel imaging. While these techniques have not been evaluated for chest venography, they appear promising [34-36].
Venous Ultrasound This relatively inexpensive test can exclude DVT and help identify a proximal venous obstruction. Diagnostic criteria for direct evidence of thrombus, as in the lower extremity, include loss of compressibility and visualization of echogenic material in the vein, whereas indirect evidence includes altered blood flow patterns [8,21-25]. Compressibility of the vein is evaluated by applying pressure to the soft tissues overlying the vein. Loss of compressibility is consistent with acute DVT but can also occur in the presence of chronic venous thrombosis [8,22]. This can be used for peripheral veins such as jugular, axillary, basilic, cephalic, and brachial veins. Compression cannot be used to evaluate subclavian or more central veins, as bony structures prevent visualization and/or compression of the veins. A full examination also includes evaluation of the Doppler velocity profiles obtained from blood in the major veins. Reduction in Doppler velocity changes due to cardiac pulsatility are reliable indicators of central venous obstruction [12,25,26]. In addition, respiratory maneuvers such as rapid inspiration or “sniffing” should cause the walls of the subclavian veins to collapse [20,26,27]. Impairment of this collapse (which is related to rapid venous emptying) also indicates a central obstructive process [10,25,26]. However, a central thrombus will cause the same alterations in blood flow as a mass encasing or compressing the central (superior vena cava, brachiocephalic) veins or a benign stricture. Color flow imaging can be used to image the presence or absence of flow within the vein and is useful in evaluating venous segments where compression maneuvers cannot be applied [8,10,26] (eg, central subclavian vein), although a study has suggested that if only blood flow ACR Appropriateness Criteria®
Contrast-enhanced MRV [32,37,38] can also be used by implementing 2D or 3D T1 gradient echo images with fat saturation after administration of a single or a double dose of MR contrast . Typically, venous imaging is carried out after an MR arteriogram by simply imaging out into the venous or equilibrium phases of contrast distribution [30,34]; new time-resolved imaging allows visualization of flow dynamics and may decrease required contrast volume and acquisition time . It has found use in protocols for whole-body venography . The advantages of MRV are primarily for central venous evaluation, as the central veins cannot be imaged directly by US. For imaging the arm itself, US or even x-ray venography is preferred. MRV of the arm is rendered more difficult by its placement at the periphery of the 3
Suspected Upper-Extremity DVT
magnetic field or the requirement to maintain the arm motionless over the head. Studies so far specifically comparing MRV to venography have been mixed, with some work showing MRV to be as effective as venography [33,38], but other work showing its limitations [24,31,32].
Anticipated Exceptions Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. It appears to be related to both underlying severe renal dysfunction and the administration of gadolinium-based contrast agents. It has occurred primarily in patients on dialysis, rarely in patients with very limited glomerular filtration rate (GFR) (ie, <30 mL/min/1.73m2), and almost never in other patients. There is growing literature regarding NSF. Although some controversy and lack of clarity remain, there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk, and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1.73m2. For more information, please see the ACR Manual on Contrast Media .
Computed Tomography CT can be used to determine the presence of centrally located thrombi or stenoses within the jugular veins [41,42], the brachiocephalic veins [43,44], and the superior vena cava . The presence of an extrinsic process causing venous obstruction of the venous channels can also be determined . Delayed imaging at 90 to 120 seconds can permit evaluation of the central veins. It is important to administer large doses of contrast (up to 150 cc) in order to ensure adequate venous opacification. New techniques involving dual injections of contrast have been developed for CT venography and look promising . No large series have looked at the diagnostic accuracy of this technique for diagnosing upper-extremity venous thrombosis, although extensive experience is accumulating with lower-extremity venous thrombosis. One small series does show CT venography to perform similarly to conventional venography in the thoracic and upper-extremity veins, as well as to evaluate the central extent of obstruction more effectively .
Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.
Despite the availability of noninvasive imaging techniques, contrast venography remains the best reference standard diagnostic test for suspected upper-extremity acute venous thrombosis.
Contrast venography may be needed whenever other noninvasive strategies fail to adequately image the upper-extremity veins. Additionally, as venography is the first step in direct catheter-based thrombolysis, in situations such as acute upper-extremity DVT where the likelihood of percutaneous thrombectomy or thrombolysis is high, it is sensible to proceed directly to venography.
Duplex, color flow, and compression ultrasound have also established a clear role in evaluation of the more peripheral veins that are accessible to sonography.
Imaging with gadolinium contrast-enhanced MRI is routinely used to evaluate the status of the central veins. Unfortunately, despite widespread clinical use, there are few validation studies compared to the literature on contrast venography. The recognition of gadolinium as a cause of nephrogenic systemic fibrosis has increased interest in noncontrast MR venography, but validation of these techniques in the chest remains an issue.
Delayed computed tomographic venography can often be used to confirm or exclude more central vein venous thrombi, although substantial contrast loads are required As in the case of MR venography, there are few correlative studies justifying this approach.
ACR Appropriateness Criteria®
Suspected Upper-Extremity DVT
14. Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologist's perspective. Semin Dial 2007; 20(1):53-62. 15. Lam EY, Giswold ME, Moneta GL. Venous and Lymphatic Disease. In: Brunicardi FC, Andersen DK, Billiar TR, et al., eds. Schwartz's Principles of Surgery. 8th ed: McGraw-Hill; 2005. 16. Hingorani AP, Ascher E, Markevich N, et al. Prospective evaluation of combined upper and lower extremity DVT. Vasc Endovascular Surg 2006; 40(2):131-134. 17. Do B, Mari C, Biswal S, Kalinyak J, Quon A, Gambhir SS. Diagnosis of aseptic deep venous thrombosis of the upper extremity in a cancer patient using fluorine-18 fluorodeoxyglucose positron emission tomography/computerized tomography (FDG PET/CT). Ann Nucl Med 2006; 20(2):151-155. 18. Gloviczki P, Calcagno D, Schirger A, et al. Noninvasive evaluation of the swollen extremity: experiences with 190 lymphoscintigraphic examinations. J Vasc Surg 1989; 9(5):683689; discussion 690. 19. Wang YF, Cherng SC, Chiu JS, Su YC, Sheu YT. Application of upper extremity radionuclide venography as a diagnostic approach for Port-A catheter thrombosis. J Chin Med Assoc 2006; 69(8):358-363. 20. Baxter GM, Kincaid W, Jeffrey RF, Millar GM, Porteous C, Morley P. Comparison of colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis. Br J Radiol 1991; 64(765):777-781. 21. Koksoy C, Kuzu A, Kutlay J, Erden I, Ozcan H, Ergin K. The diagnostic value of colour Doppler ultrasound in central venous catheter related thrombosis. Clin Radiol 1995; 50(10):687-689. 22. Weissleder R, Elizondo G, Stark DD. Sonographic diagnosis of subclavian and internal jugular vein thrombosis. J Ultrasound Med 1987; 6(10):577-587. 23. Chin EE, Zimmerman PT, Grant EG. Sonographic evaluation of upper extremity deep venous thrombosis. J Ultrasound Med 2005; 24(6):829-838; quiz 839-840. 24. Haire WD, Lynch TG, Lund GB, Lieberman RP, Edney JA. Limitations of magnetic resonance imaging and ultrasounddirected (duplex) scanning in the diagnosis of subclavian vein thrombosis. J Vasc Surg 1991; 13(3):391-397. 25. Svensson WE, Mortimer PS, Tohno E, Cosgrove DO. Colour Doppler demonstrates venous flow abnormalities in breast cancer patients with chronic arm swelling. Eur J Cancer 1994; 30A(5):657-660. 26. Weber TM, Lockhart ME, Robbin ML. Upper extremity venous Doppler ultrasound. Radiol Clin North Am 2007; 45(3):513-524. 27. Grassi CJ, Polak JF. Axillary and subclavian venous thrombosis: follow-up evaluation with color Doppler flow US and venography. Radiology 1990; 175(3):651-654. 28. Gaitini D, Beck-Razi N, Haim N, Brenner B. Prevalence of upper extremity deep venous thrombosis diagnosed by color Doppler duplex sonography in cancer patients with central venous catheters. J Ultrasound Med 2006; 25(10):1297-1303. 29. Haire WD, Lynch TG, Lieberman RP, Lund GB, Edney JA. Utility of duplex ultrasound in the diagnosis of asymptomatic catheterinduced subclavian vein thrombosis. J Ultrasound Med 1991; 10(9):493-496. 30. Ho VB, Corse WR, Hood MD, Rowedder AM. Magnetic resonance angiography of the thoracic vessels. Magnetic Resonance Imaging Clinics of North America 2004; 12(4):727747. 31. Hansen ME, Spritzer CE, Sostman HD. Assessing the patency of mediastinal and thoracic inlet veins: value of MR imaging. AJR 1990; 155(6):1177-1182. 32. Baarslag HJ, Van Beek EJ, Reekers JA. Magnetic resonance venography in consecutive patients with suspected deep vein thrombosis of the upper extremity: initial experience. Acta Radiol 2004; 45(1):38-43. 33. Finn JP, Zisk JH, Edelman RR, et al. Central venous occlusion: MR angiography. Radiology 1993; 187(1):245-251. 34. Vogt FM, Herborn CU, Goyen M. MR venography. Magn Reson Imaging Clin N Am 2005; 13(1):113-129, vi. 35. Cantwell CP, Cradock A, Bruzzi J, Fitzpatrick P, Eustace S, Murray JG. MR venography with true fast imaging with steadystate precession for suspected lower-limb deep vein thrombosis. J Vasc Interv Radiol 2006; 17(11 Pt 1):1763-1769. 36. Miyazaki M, Sugiura S, Tateishi F, Wada H, Kassai Y, Abe H. Non-contrast-enhanced MR angiography using 3D ECG-
Relative Radiation Level Designations Relative Radiation Level* O
Adult Effective Dose Estimate Range 0 mSv
Pediatric Effective Dose Estimate Range 0 mSv
30-100 mSv 10-30 mSv ☢☢☢☢☢ *RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as NS (not specified). Supporting Document(s) •
ACR Appropriateness Criteria® Overview
Procedure Contrast Information
References 1. 2.
Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation 2002; 106(14):1874-1880. Weissleder H, Weissleder R. Lymphedema: evaluation of qualitative and quantitative lymphoscintigraphy in 238 patients. Radiology 1988; 167(3):729-735. Abdullah BJ, Mohammad N, Sangkar JV, et al. Incidence of upper limb venous thrombosis associated with peripherally inserted central catheters (PICC). Br J Radiol 2005; 78(931):596-600. Baarslag HJ, Koopman MM, Reekers JA, van Beek EJ. Diagnosis and management of deep vein thrombosis of the upper extremity: a review. Eur Radiol 2004; 14(7):1263-1274. Prandoni P, Polistena P, Bernardi E, et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med 1997; 157(1):57-62. Schmittling ZC, McLafferty RB, Bohannon WT, Ramsey DE, Hodgson KJ. Characterization and probability of upper extremity deep venous thrombosis. Ann Vasc Surg 2004; 18(5):552-557. Spencer FA, Emery C, Lessard D, Goldberg RJ. Upper extremity deep vein thrombosis: a community-based perspective. Am J Med 2007; 120(8):678-684. Baarslag HJ, van Beek EJ, Koopman MM, Reekers JA. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities. Ann Intern Med 2002; 136(12):865-872. Shebel ND, Marin A. Effort thrombosis (Paget-Schroetter syndrome) in active young adults: current concepts in diagnosis and treatment. J Vasc Nurs 2006; 24(4):116-126. Knudson GJ, Wiedmeyer DA, Erickson SJ, et al. Color Doppler sonographic imaging in the assessment of upper-extremity deep venous thrombosis. AJR 1990; 154(2):399-403. Mustafa S, Stein PD, Patel KC, Otten TR, Holmes R, Silbergleit A. Upper extremity deep venous thrombosis. Chest 2003; 123(6):1953-1956. Patel MC, Berman LH, Moss HA, McPherson SJ. Subclavian and internal jugular veins at Doppler US: abnormal cardiac pulsatility and respiratory phasicity as a predictor of complete central occlusion. Radiology 1999; 211(2):579-583. Ong B, Gibbs H, Catchpole I, Hetherington R, Harper J. Peripherally inserted central catheters and upper extremity deep vein thrombosis. Australas Radiol 2006; 50(5):451-454.
ACR Appropriateness Criteria®
Suspected Upper-Extremity DVT
synchronized half-Fourier fast spin echo. J Magn Reson Imaging 2000; 12(5):776-783. Denson K, Morgan D, Cunningham R, et al. Incidence of venous thromboembolism in patients with traumatic brain injury. Am J Surg 2007; 193(3):380-383; discussion 383-384. Tanju S, Sancak T, Dusunceli E, Yagmurlu B, Erden I, Sanlidilek U. Direct contrast-enhanced 3D MR venography evaluation of upper extremity deep venous system. Diagn Interv Radiol 2006; 12(2):74-79. Kim CY, Mirza RA, Bryant JA, et al. Central Veins of the Chest: Evaluation with Time-resolved MR Angiography. Radiology 2008; 247:Epub Mar 18, 2008. Ruehm S KK, Bosk S, et al. Thromboembolic disease: Assessment with whole body MR venography. Academic Radiology 2005; 12(5, Supplement 1):S63. Panzironi G, Rainaldi R, Ricci F, Casale A, De Vargas Macciucca M. Gray-scale and color Doppler findings in bilateral internal jugular vein thrombosis caused by anaplastic carcinoma of the thyroid. J Clin Ultrasound 2003; 31(2):111-115.
42. Stam J. Thrombosis of the cerebral veins and sinuses. N Engl J Med 2005; 352(17):1791-1798. 43. Kim HC, Chung JW, Yoon CJ, et al. Collateral pathways in thoracic central venous obstruction: three-dimensional display using direct spiral computed tomography venography. J Comput Assist Tomogr 2004; 28(1):24-33. 44. Sabharwal R, Boshell D, Vladica P. Multidetector spiral CT venography in the diagnosis of upper extremity deep venous thrombosis. Australas Radiol 2007; 51 Suppl:B253-256. 45. Kim H, Chung JW, Park JH, et al. Role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction. Korean J Radiol 2003; 4(3):146-152. 46. New CT Protocol Yields Improved Venous Images. RSNA News 2008; 18(1):6-7. 47. American College of Radiology. Manual on Contrast Media. Available at: http://www.acr.org/SecondaryMainMenuCategories/ quality_safety/contrast_manual.aspx.
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.