Which MRI to order for unilateral papilledema?

[Edward Melman]

One of my patients, a 70 y/o WF, came in yesterday for routine monitoring of her cataracts and drusen.

I found a unilateral swollen right disk with hemorrhages and additional dot hemes in the macula and blot hemes in the periphery. She claimed to be totally asymptomatic and her vision was OD 20/25 and OS 20/20, the same as when I saw her in January when her disk was normal.\

She has a history of breast cancer and a pacemaker for arrhythmia. She had bilateral blepharoplasties in January 2024 and the only meds were Metoprolol and baby aspirin. She is very claustrophobic and hates MRI's but had one for her knee surgery at Penn.

I referred her to the Wills Eye ER where they did extensive blood work and discharged her at 2:00 AM this morning with instructions to have me request an MRI at Penn. The problem is the pacemaker makes the MRI more dangerous and Penn said they would only do it for a Penn doctor since it requires more elaborate monitoring.

She would also probably require some sedation due to her anxiety in tight spaces. I looked up the CPT4 codes and while normally a brain scan 70553 wo/w contrast would be indicated for bilateral papilledema I think the 70543 code for MRI of the orbit is more appropriate for unilateral disk edema. I've had very limited experience in ordering MRI's so would appreciate advice. Which MRI to order and how do I find an MRI site that would be able to handle this type of case and accept an outside script?

I have optomap photos but I'm not sure how to delete her name from them.

 

[Lloyd Pate]

One of my patients, a 70 y/o WF, came in yesterday for routine monitoring of her cataracts and drusen. I found a unilateral swollen right disk with hemorrhages and additional dot hemes in the macula and blot hemes in the periphery. She claimed to be totally asymptomatic and her vision was OD 20/25 and OS 20/20, the same as when I saw her in January when her disk was normal. She has a history of breast cancer and a pacemaker for arrhythmia. She had bilateral blepharoplasties in January 2024 and the only meds were Metoprolol and baby aspirin. She is very agorophobic and hates MRI's but had one for her knee surgery at Penn. I referred her to the Wills Eye ER where they did extensive blood work and discharged her at 2:00 AM this morning with instructions to have me request an MRI at Penn. The problem is the pacemaker makes the MRI more dangerous and Penn said they would only do it for a Penn doctor since it requires more elaborate monitoring. She would also probably require some sedation due to her anxiety in tight spaces. I looked up the CPT4 codes and while normally a brain scan 70553 wo/w contrast would be indicated for bilateral papilledema I think the 70543 code for MRI of the orbit is more appropriate for unilateral disk edema. I've had very limited experience in ordering MRI's so would appreciate advice. Which MRI to order and how do I find an MRI site that would be able to handle this type of case and accept an outside script?
I have optomap photos but I'm not sure how to delete her name from them.

MRI brain w/wo and MRI orbits w/wo with fat suppression.

 

[Edward Melman]

MRI brain w/wo and MRI orbits w/wo with fat suppression.

Thanks, I did decide on both. I may need to refer her to the Penn ED to get her seen.

 

[Jeffrey Kiener]

Of course it could be anything, but I ask anyone:

1. Is unilateral papilledema a strong diagnosis?
2. With disc hemorrhages, macular hemorrhages doesn't this sound more like a CRVO?
3. Demographic may weigh more towards a vascular vs. compressive etiology?
4. Even if it is a neuritis, we don't have extensive vision information...could there be a VF defect that leads to that diagnosis?
5. Isn't arteritic ION a big risk, here, too? Need at least history on that, and probably the obligatory ESR for what that's worth. I guess that's what Wills did?

I would appreciate discussion on those perceptions.

 

[Lloyd Pate]

Of course it could be anything, but I ask anyone:

1. Is unilateral papilledema a strong diagnosis?
2. With disc hemorrhages, macular hemorrhages doesn't this sound more like a CRVO?
3. Demographic may weigh more towards a vascular vs. compressive etiology?
4. Even if it is a neuritis, we don't have extensive vision information...could there be a VF defect that leads to that diagnosis?
5. Isn't arteritic ION a big risk, here, too? Need at least history on that, and probably the obligatory ESR for what that's worth. I guess that's what Wills did?

I would appreciate discussion on those perceptions.

1. Yes, 2% of papilledema cases are unilateral.
https://www.nature.com/articles/6702131
https://pn.bmj.com/content/17/4/310
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602232/

2. Maybe it is a partial occlusion, but you need an MRI to rule out a compressive etiology.

3. Vascular might be right 90% of the time, but do you have an obligation to the other 10% to find the cause and not just jump to the most common but incorrect diagnosis?

4. Yes, a VF would be nice, but I would not rely on it to not do an MRI.

5. Yes, you can order the blood tests and the MRI simultaneously. Wills should have done it. It is malpractice if they did not. She is also not symptomatic for AION.

 

[Lloyd Pate]

Here is the American College of Radiology guidelines

4

Suspected optic neuritis. Initial imaging.​

15

Name	Category	Adult RRL	Peds RRL
MRI head without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI orbits without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI orbits without IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]

 

[Lloyd Pate]

6

Visual loss. Intraocular mass,optic nerve, or pre-chiasm symptoms. Initial imaging.​

15

Name	Category	Adult RRL	Peds RRL
MRI orbits without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI orbits without IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
CT orbits with IV contrast	Usually appropriate	☢☢☢ 1-10 mSv

 

[Lloyd Pate]

7

Nonischemic visual loss. Chiasm or post-chiasm symptoms. Initial imaging.​

18

Name	Category	Adult RRL	Peds RRL
MRI head without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI head without IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]

 

[Lloyd Pate]

Ophthalmoplegia or diplopia. Initial imaging.​

15

Name	Category	Adult RRL	Peds RRL
MRI head without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI orbits without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI orbits without IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
CT orbits with IV contrast	Usually appropriate	☢☢☢ 1-10 mSv	☢☢☢ 0.3-3 mSv [ped]

 

[Lloyd Pate]

4

Headache with features of intracranial hypertension (eg, papilledema, pulsatile tinnitus, visual symptoms worse on Valsalva). Initial imaging.​

15

Priority Clinical Areas: Headache (traumatic and nontraumatic)

Name	Category	Adult RRL	Peds RRL
MRI head without and with IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
MRI head without IV contrast	Usually appropriate	O 0 mSv	O 0 mSv [ped]
CT head without IV contrast	Usually appropriate	☢☢☢ 1-10 mSv	☢☢☢ 0.3-3 mSv [ped]
MRV head with IV contrast	May be appropriate	O 0 mSv	O 0 mSv [ped]
MRV head without and with IV contrast	May be appropriate	O 0 mSv	O 0 mSv [ped]
MRV head without IV contrast	May be appropriate	O 0 mSv	O 0 mSv [ped]

 

[Lloyd Pate]

Look at the age of peak incidence. Would you consider a tumor? What about the history of breast cancer?

 

[Edward Melman]

View attachment 44168

Look at the age of peak incidence. Would you consider a tumor? What about the history of breast cancer?

 

[Mike Alvarez]

1. Yes, 2% of papilledema cases are unilateral.
https://www.nature.com/articles/6702131
https://pn.bmj.com/content/17/4/310
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602232/

2. Maybe it is a partial occlusion, but you need an MRI to rule out a compressive etiology.

3. Vascular might be right 90% of the time, but do you have an obligation to the other 10% to find the cause and not just jump to the most common but incorrect diagnosis?

4. Yes, a VF would be nice, but I would not rely on it to not do an MRI.

5. Yes, you can order the blood tests and the MRI simultaneously. Wills should have done it. It is malpractice if they did not. She is also not symptomatic for AION.

I’d swear I was taught that papilledema was always bilateral since it was caused by increased intracranial pressure which should affect both nerves

 

[Edward Melman]

A critical issue in this case was the presence of a pacemaker. I'm not sure if her pacemaker is MRI compatible but she had one previously so it probably is. It's recommended that a cardiologist and radiologist be closely monitoring during the testing which obviously increases the cost and complexity. Her bp was 131/77 during my exam. I've requested the ER report from Wills but haven't seen anything yet. Thank to Lloyd and Jeff for this discussion.
"
An MRI scan can be performed on patients with a pacemaker if the pacemaker is MRI-compatible and special protocols are followed. MRI scanners use strong magnetic fields that can affect metal implants, including pacemakers and their wires. These magnets can potentially damage the pacemaker, change its settings, or heat the metal in the device, which could harm heart tissue. However, doctors can use protocols to minimize these risks, such as:

• Setting the pacemaker to a safe mode before the scan
• Monitoring the patient closely during the procedure
• Reprogramming the pacemaker after the scan
• Performing the exam at a well-equipped center with experienced staff
• Having a radiologist and cardiologist present during the exam "

 

[Lloyd Pate]

A critical issue in this case was the presence of a pacemaker. I'm not sure if her pacemaker is MRI compatible but she had one previously so it probably is. It's recommended that a cardiologist and radiologist be closely monitoring during the testing which obviously increases the cost and complexity. Her bp was 131/77 during my exam. I've requested the ER report from Wills but haven't seen anything yet. Thank to Lloyd and Jeff for this discussion.
"
An MRI scan can be performed on patients with a pacemaker if the pacemaker is MRI-compatible and special protocols are followed. MRI scanners use strong magnetic fields that can affect metal implants, including pacemakers and their wires. These magnets can potentially damage the pacemaker, change its settings, or heat the metal in the device, which could harm heart tissue. However, doctors can use protocols to minimize these risks, such as:

• Setting the pacemaker to a safe mode before the scan
• Monitoring the patient closely during the procedure
• Reprogramming the pacemaker after the scan
• Performing the exam at a well-equipped center with experienced staff
• Having a radiologist and cardiologist present during the exam "

In the journals​

Magnetic resonance imaging (MRI) has long been considered dangerous for people who have electronic heart devices like pacemakers and defibrillators implanted in their bodies. Now, a study published online Aug. 14, 2017, by the Journal of Clinical Electrophysiology suggests the scans are safe for most people with these devices.

Until recently, most devices were not FDA-approved for MRI. They had been considered risky because it was feared that the high-strength magnetic fields used for the scanning could disrupt a pacemaker's or defibrillator's circuits. Yet, when researchers reviewed 212 MRI examinations involving 178 patients with these nonapproved devices, they did not find a single problem with how they functioned. The researchers concluded that MRI is safe for someone with a device implanted after 2000, as long as the device is checked before and after the procedure and its pacing function is monitored during the scan.

In the last seven years, the FDA has approved newer and more expensive devices that are designed to be safe for MRI; these are labeled "MRI conditional." However, the researchers noted that you don't need to replace your older device with an MRI-compatible model before getting a scan.

https://www.health.harvard.edu/hear...ost-people-with-pacemakers-and-defibrillators

 

[Jeffrey Kiener]

Wow. Lloyd, thank you so much for your efforts.

 

[Jeffrey Kiener]

That tumor incidence chart is enlightening. I would have thought otherwise.

It seems like in the early ages, it follows major growth rates. But after a minimum in the 20's, by thirty it's almost linear, but almost goes exponential at retirement age.

(At 80, I'm willing to bet that there's another confounding statistical factor that drops it back down.)

 

[Lloyd Pate]

That tumor incidence chart is enlightening. I would have thought otherwise.

It seems like in the early ages, it follows major growth rates. But after a minimum in the 20's, by thirty it's almost linear, but almost goes exponential at retirement age.

(At 80, I'm willing to bet that there's another confounding statistical factor that drops it back down.)

Have you considered Pseudo-Foster Kennedy Syndrome?

 

[Jeffrey Kiener]

No but Dr. Google has:

Pseudo-Foster Kennedy Syndrome is described as unilateral optic disc swelling with contralateral optic atrophy in the absence of an intracranial mass causing compression of the optic nerve. This occurs typically due to bilateral sequential optic neuritis or ischaemic optic neuropathy.

 

[Jeffrey Kiener]

I guess the determinant would be the visual function (and color) of the "non-swollen" nerve. I would guess the "non-swollen" nerve would have pallor and reduced VA/VF.

 

[Edward Melman]

I guess the determinant would be the visual function (and color) of the "non-swollen" nerve. I would guess the "non-swollen" nerve would have pallor and reduced VA/VF.

There was no pallor or reduced VA in the contralateral left eye

 

[Lloyd Pate]

No but Dr. Google has:

Pseudo-Foster Kennedy Syndrome is described as unilateral optic disc swelling with contralateral optic atrophy in the absence of an intracranial mass causing compression of the optic nerve. This occurs typically due to bilateral sequential optic neuritis or ischaemic optic neuropathy.

What about real Foster Kennedy?

Ain't neuro fun.

 

[Lloyd Pate]

I guess the determinant would be the visual function (and color) of the "non-swollen" nerve. I would guess the "non-swollen" nerve would have pallor and reduced VA/VF.

Yep, fields, color vision and BVA are affected.

 

[Lloyd Pate]

There was no pallor or reduced VA in the contralateral left eye

Just throwing out things to think about in unilateral disc edema.

 

[Matt Judd]

Curious: how was her bp?

I find the unilateral swollen nerve w/ hemorrhages concerning every time.
straight to MRI. a lot of times I think the other eye was fine but an OCT nerve shows slightly elevation

 

[Gretchyn Bailey]

We had the pacemaker problem with MRI about a month ago with my late mother-in-law. We never did get her one before she passed away.

 

[Matt Judd]

saw a guy this morning. diabetic. poor health. upper 60s. last seen 3 years ago.

he had a retinal hemorrhage (at that time) that wasnt indicative of diabetic retinopathy per se. jumped thru many hoops to get the proper testing.

today, several stints, pacemaker, and had a stroke that affected his short term memory and speech. Had we not gotten him for proper testing hed likely be dead

 

[Edward Melman]

Curious: how was her bp?

I find the unilateral swollen nerve w/ hemorrhages concerning every time.
straight to MRI. a lot of times I think the other eye was fine but an OCT nerve shows slightly elevation

Hi Matt.

BP was 131/77 at the exam.
I just received the ER test results. CT scan completely clean. No lesions visible around the orbit or brain, no bleeding or compression visible.

CT was interesting with clear image of pacemaker and I was able to scan from back of brain, through the ventricles till the orbit. No significant blood work abnormalities. Glucose 102, a1c 5.3, slight ALT elevation, normal CBC and no infectious disease positives. MRI will give more detail but I'll be surprised if there are any gross findings.

She has an appointment with Neurooph in September.

 

[Matt Judd]

interesting. I assume you ran the bloodwork for usual suspects.

you think its just idiopathic?

 

[Edward Melman]

interesting. I assume you ran the bloodwork for usual suspects.

you think its just idiopathic?

I haven't encountered anything like this but suspect she has a clot in the nerve sheath and the origin is vasculopathic as Jeff and Lloyd have suggested was most likely.

 

[Matt Judd]

interesting case. thanks for sharing!