Brain (Head) MRA/MRV - CAM 755

Description
Magnetic resonance angiography (MRA) or magnetic resonance venography (MRV) can be used as a first-line investigation of intracranial vascular disease. It is an alternative to invasive intra-catheter angiography that was once the mainstay for the investigation of intracranial vascular disease. MRA/MRV may use a contrast agent, gadolinium, which is non-iodine-based, for better visualization. It can be used in patients who have history of contrast allergy and who are at high risk of kidney failure. A single authorization covers both MRA and MRV.

The three different techniques of MRA/MRV include time of flight (both 2D and 3D TOF), phase contrast (PC), and contrast-enhanced angiography. Time of flight MRA takes advantage of the phenomena of flow-related enhancement and is the preferred MRA technique due to the speed at which the exam can be acquired.

MRA and Cerebral Aneurysms – Studies that compared MRA with catheter angiography in detecting aneurysms found that MRA could find 77% - 94% of the aneurysms previously diagnosed by catheter angiography that were larger than 5 mm. For aneurysms smaller than 5 mm, MRI detected only 10% - 60% of those detected with catheter angiography. On the other hand, aneurysms that were missed by catheter angiography in patients with acute subarachnoid hemorrhage were detected with MRA, due to the much larger number of projections available with MRA (Chen, 2018).

MRA and Cerebral Arteriovenous Malformations (AVM) – Brain arteriovenous malformation (AVM) may cause intracranial hemorrhage and is usually treated by surgery. 3D TOF-MRA is commonly used during the planning of radio-surgery to delineate the AVM nidus, but it is not highly specific for the detection of a small residual AVM after radio-surgery.

MRA and non-aneurysmal vascular malformations – Non-aneurysmal vascular malformations can be divided in low flow vascular malformations and high flow vascular malformations. Low flow vascular malformations include dural venous anomalies (DVA), cavernomas, and capillary telangiectasias. High flow vascular malformations include AVM and dural arteriovenous fistulas (dAVF). For low flow malformations, MRI is the study of choice. There is limited medical literature to support vascular imagining (CTA or MRA). CTA plays a limited role in the assessment of cavernoma but may be used to demonstrate a DVA. MRA is not usually helpful in the assessment of cavernoma, capillary telangiectasia, and DVA. Vascular imaging is indicated in high flow vascular malformations (Lee, 2012; Robertson, 2020; Salmela, 2017).

MRA and recent stroke or transient ischemic attack – A stroke or central nervous system infarction is defined as "brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. … Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, whereas silent infarction causes no known symptoms” (Sacco, 2013). If imaging or pathology is not available, a clinical stroke is diagnosed by symptoms persisting for more than 24 hours. Ischemic stroke can be further classified by the type and location of ischemia and the presumed etiology of the brain injury. These include large-artery atherosclerotic occlusion (extracranial or intracranial), cardiac embolism, small-vessel disease and less commonly dissection, hypercoagulable states, sickle cell disease and undetermined causes (Kernan, 2014). TIAs in contrast, “are a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction on imaging” (Easton, 2009). On average, the annual risk of future ischemic stroke after a TIA or initial ischemic stroke is 3–4%, with an incidence as high as 11% over the next 7 days and 24–29% over the following 5 years. This has significantly decreased in the last half century due to advances in secondary prevention (Hong, 2011).

Therefore, when revascularization therapy is not indicated or available in patients with an ischemic stroke or TIA, the focus of the work-up is on secondary prevention. This includes noninvasive vascular imaging to identify the underlying etiology, assess immediate complications and risk of future stroke. The majority of stroke evaluations take place in the inpatient setting. Admitting TIA patients is reasonable if they present within 72 hours and have an ABCD(2) score ≥ 3, indicating high risk of early recurrence, or the evaluation cannot be rapidly completed on an outpatient basis (Easton, 2009). Minimally, both stroke and TIA should have an evaluation for high-risk modifiable factors, such as carotid stenosis atrial fibrillation, as the cause of ischemic symptoms (Kernan, 2014). Diagnostic recommendations include neuroimaging evaluation as soon as possible, preferably with magnetic resonance imaging, including DWI; noninvasive imaging of the extracranial vessels should be performed, and noninvasive imaging of intracranial vessels is reasonable (Wintermark, 2013).

Patients with a history of stroke and recent workup with new signs or symptoms indicating progression or complications of the initial CVA should have repeat brain imaging as an initial study. Patients with remote or silent strokes discovered on imaging should be evaluated for high-risk modifiable risk factors based on the location and type of the presumed etiology of the brain injury.

MRA and Intracerebral Hemorrhage – MRA is useful as a screening tool for an underlying vascular abnormality (Bekelis, 2012) in the evaluation of spontaneous intracerebral hemorrhage (ICH). Etiologies of spontaneous ICH include tumor, vascular malformation, aneurysm, hypertensive arteriopathy, cerebral amyloid angiopathy, venous thrombosis, vasculitis, RCVS, drug-induced vasospasm, venous sinus thrombosis, Moyomoya disease, anticoagulant use and hemorrhagic transformation of an ischemic infarct. History can help point to a specific etiology. Possible risk factors for the presence of underlying vascular abnormalities include age younger than 65, female, lobar or intraventricular location, and the absence of hypertension or impaired coagulation.

MRV - A pitfall of the TOF technique, particularly 3D TOF, is that in areas of slowly flowing blood, turbulence, or blood which flows in the imaging plane there can be regions of absent or diminished signal. The signal loss can be confused with vascular occlusion or thrombi. To avoid this pitfall, MRA performed after the intravenous administration of gadolinium-based contrast agents is utilized at many facilities.

Intracranial magnetic resonance venography (MRV) is used primarily to evaluate the patency of the venous sinuses. The study can be performed with TOF, Phase contrast and IV contrast-enhanced techniques. Delayed images to allow for enhancement of the venous system are required to obtain images when intravenous gadolinium-enhanced studies are undertaken.

Saturation pulses are utilized in studies not undertaken with intravenous contrast to help eliminate flow-related signal in a specified direction and thus display the desired arterial or venous structures on their own. In cranial applications, saturation pulses applied at the inferior margin of the imaging field eliminate signal from arterial flow in order to visualize the veins. Conversely, superior saturation pulses are used to eliminate venous flow-related enhancement when evaluation of the arterial structures is desired (Ayanzen, 2000).

†MRV and Central Venous Thrombosis – a MR Venogram is indicated for the evaluation of a central venous thrombosis/dural sinus thrombosis. The most frequent presentations are isolated headache, intracranial hypertension syndrome, seizures, focal neurological deficits, and encephalopathy. Risk factors are hypercoagulable states inducing genetic prothrombotic conditions, antiphospholipid syndrome and other acquired prothrombotic diseases (such as cancer), oral contraceptives, pregnancy, puerperium (6 weeks postpartum), infections, and trauma. COVID-19 infection is associated with hypercoagulability, a thromboinflammatory response, and an increased incidence of venous thromboembolic events (VTE) (Connors, 2020; Tu, 2020). Since venous thrombosis can cause SAH, infarctions, and hemorrhage, parenchymal imaging with MRI/CT is also appropriate (Bushnell, 2014; Coutinho, 2015; Ferro, 2016).

Combination MRI/MRA of the Brain – This is one of the most misused combination studies and other than what is indicated above these examinations should be ordered in sequence, not together. Vascular abnormalities can be visualized on the brain MRI.

Patients presenting with a new migraine with aura (especially an atypical or complex aura) can mimic a transient ischemic attack or an acute stroke. If there is a new neurologic deficit, imaging should be guided by concern for cerebrovascular disease, not that the patient has a headache (Whitehead, 2019).

MRA and dissection- Craniocervical dissections can be spontaneous or traumatic. Patients with blunt head or neck trauma who meet Denver Screening criteria should be assessed for cerebrovascular injury (although about 20% will not meet criteria). The criteria include focal or lateralizing neurological deficits (not explained by head CT); infarct on head CT; face, basilar skull, or cervical spine fractures; cervical hematomas that are not expanding; glasgow coma score less than 8 without CT findings; massive epistaxis; cervical bruit or thrill (Franz, 2012; Liang, 2013; Mundinger, 2013; Simon, 2019). Spontaneous dissection presents with headache, neck pain with neurological signs or symptoms. There is often minor trauma or precipitating factor (i.e., exercise, neck manipulation). Dissection is thought to occur due to weakness of the vessel wall, and there may be an underlying connective tissue disorder. Dissection of the extracranial vessels can extend intracranially and/or lead to thrombus which can migrate into the intracranial circulation, causing ischemia. Therefore, MRA of the head and neck is warranted (Nash, 2019; Shakir, 2016).

Policy 
INDICATIONS FOR BRAIN (HEAD) MR Angiography/MRVenography:

Brain MRI/MRA are not approvable simultaneously unless they meet the criteria described below in the Indications for Brain MRI/Brain MRA combination studies section.

For evaluation of suspected intracranial vascular disease (Robertson, 2020; Salmela, 2017) 

  • Aneurysm screening
    • Screening for suspected intracranial aneurysm in patient with a first-degree familial history (parent brother, sister, or child) of intracranial aneurysm 

Note: Repeat study is recommended every 5 years (Chalouhi, 2011) 

    • Screening for aneurysm in polycystic kidney disease (after age 30), Loeys-Dietz syndrome*, fibromuscular dysplasia, spontaneous coronary arteries dissection (SCAD), or known aortic coarctation (Hayes, 2018; Hitchcock, 2017; Macaya, 2019)  

*For Loeys-Dietz imaging should be repeated at least every two years 

  • Vascular abnormalities
    • Suspected vascular malformation (arteriovenous malformation (AVM) or dural arteriovenous fistula) in patient with previous or indeterminate imaging study
    • Thunderclap headache with continued concern for underlying vascular abnormality after initial negative work-up (Whitehead, 2019, Yeh, 2010, Yuan, 2005):
      • Negative Brain CT AND Negative Lumbar Puncture OR
      • Negative Brain MRI
    • Headache associated with exercise or sexual activity (IHS, 2018)
    • Isolated third nerve palsy (oculomotor) with pupil involvement to evaluate for aneurysm (Pula, 2016).
    • Pulsatile tinnitus to identify a vascular etiology (Hofmann, 2013; Pegge, 2017).

NoteMRI is the study of choice for detecting cavernomas (Morrison, 2016; Zyck, 2021)   

  • Cerebrovascular Disease 
    • Ischemic
      • Recent ischemic stroke or transient ischemic attack (See Background section) (Sanelli, 2014; Wintermark, 2013)
      • Known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia, weakness in both sides of the body, or abnormal speech (Lima-Neto, 2017; Pirau, 2019; Searls, 2012)
    • Hemorrhagic
      • Known subarachnoid hemorrhage (SAH)
      • Known cerebral intraparenchymal hemorrhage with concern for underlying vascular abnormality
    • Venous-MRV* 
      • Suspected central venous thrombosis (dural sinus thrombosis) (Ferro, 2017; Saposnik, 2011)
      • Distinguishing benign intracranial hypertension (pseudotumor cerebri) from dural sinus thrombosis (Agarwal, 2010; Aldossary, 2018)
    • Sickle cells disease (ischemic and/or hemorrhagic) (Abboud, 2003; Thust, 2014)
      • Neurological signs or symptoms in sickle cell patients
      • High stroke risk in sickle cell patients (2 - 16 years of age) with a transcranial doppler velocity > 200
  • Vasculitis with initial laboratory workup (such as ESR, CRP, serology) (Berlit, 2014)
    • Suspected secondary CNS vasculitis based on neurological sign or symptoms in the setting of an underlying systemic disease with abnormal inflammatory markers or autoimmune antibodies
    • Suspected primary CNS vasculitis based on neurological signs and symptoms with completed infectious/inflammatory lab work-up (Godasi, 2019; Zuccoli, 2011)
    • Giant cell arteritis with suspected intracranial involvement (Abdel Razek, 2014; Halbach, 2018; Khan, 2015; Koster, 2018)
  • Other intracranial vascular disease
    • Suspected Moyomoya disease (Ancelet, 2015; Tarasow, 2011)
    • Suspected reversible cerebral vasoconstriction syndrome (Singhal, 2016)

For evaluation of known intracranial vascular disease (Robertson, 2020; Salmela, 2017) 

  • Known intracranial aneurysm or vascular malformation (i.e., AVM or dural arteriovenous fistula)
  • Vascular abnormality visualized on previous brain imaging that is equivocal or needs further evaluation
  • Known vertebrobasilar insufficiency with new or worsening signs or symptoms (Lima-Neto, 2017; Searls, 2012)
  • Known vasculitis, reversible cerebral vasoconstriction syndrome or Moyomoya disease (Ancelet, 2015; Godasi, 2019; Obusez, 2014; Signhal, 2016; Tarasow, 2011)

Pre-operative/procedural evaluation for brain/skull surgery 

  • Pre-operative evaluation for a planned surgery or procedure
  • Refractory trigeminal neuralgia when done for surgical planning (Leal, 2010)

Post-operative/procedural evaluation (Lee, 2015; Serafin, 2012) 

  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested

Indications for Brain MRA/Neck MRA combination studies (Robertson, 2020; Salmela, 2017)  

  • Recent ischemic stroke or transient ischemic attack (TIA) (Sanelli, 2014)
  • Known or suspected vertebrobasilar insufficiency (VBI) in patients with symptoms such as dizziness, vertigo, headaches, diplopia, blindness, vomiting, ataxia, weakness in both sides of the body, or abnormal speech (Lima-Neto, 2017; Pirau, 2019; Searls, 2012)
  • Suspected carotid or vertebral artery dissection; due to trauma or spontaneous due to weakness of vessel wall (Franz, 2012; Shakir, 2016)
  • Asymptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g., carotid stenosis ≥ 70%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate (Brott, 2011; DaCosta, 2019; Marquardt, 2010)
  • Symptomatic patients with an abnormal ultrasound of the neck or carotid duplex imaging (e.g., carotid stenosis ≥ 50%, technically limited study, aberrant direction of flow in the carotid or vertebral arteries) and patient is surgery or angioplasty candidate (Brott, 2011; Rerkasem, 2011)
  • Pulsatile tinnitus to identify vascular etiology (Hofmann, 2013; Pegge, 2017)

Indications for Brain MRI/Brain MRA combination studies (Robertson, 2020; Salmela, 2017) 

  • Recent ischemic stroke or transient ischemic attack
  • Thunderclap headache with continued concern for underlying vascular abnormality after initial negative work-up (Whitehead, 2019, Yeh, 2010, Yuan, 2005):
    • Negative Brain CT; AND
    • Negative Lumbar Puncture
  • Acute, sudden onset of headache with personal history of a vascular abnormality or first-degree family history of aneurysm
  • Headache associated with exercise or sexual activity (IHS, 2018)
  • Suspected venous thrombosis (dural sinus thrombosis) – MRV†

Indications for Brain MRI/Brain MRA/Neck MRA combination studies 

  • Recent ischemic stroke or transient ischemic attack (TIA) (Robertson, 2020; Salmela, 2017)
  • Approved indications as noted above and being performed in a child under 8 years of age who will need anesthesia for the procedure and there is a suspicion of concurrent intracranial pathology (Lawson, 2000)

References   

  1. Abboud MR, Cure J, Granger S, et al. Magnetic resonance angiography in children with sickle cell disease and abnormal transcranial Doppler ultrasonography findings enrolled in the STOP study. [Epub December 18, 2003]. Blood. 2004. doi: 10.1182/blood-2003-06-1972.
  2. Abdel Razek AA, Alvarez H, Bagg S, et al. Imaging spectrum of CNS vasculitis. Radiographics. 2014 Jul-Aug; 34(4):873-94).
  3. Agarwal P, Kumar M, Arora V. Clinical profile of cerebral venous sinus thrombosis and the role of imaging in its diagnosis in patients with presumed idiopathic intracranial hypertension. Indian J Ophthalmol. 2010 Mar-Apr; 58(2:153-5.
  4. Aldossary NM. Value of double - track sign in differentiating primary from thrombosed transverse sinus stenosis in patients presumed to have idiopathic intracranial hypertension. eNeurologicalSci. 2018 Jan 16; 10:22–25.
  5. Ancelet C, Boulouis G, Blauwblomme T, et al. Imaging Moya-Moya disease. Rev Neurol (Paris). 2015 Jan; 171(1):45-57. Epub 2014 Dec 30.
  6. Ayanzen RH, Bird CR, Keller PJ, et al. Cerebral MR venography: Normal anatomy and potential diagnostic pitfalls. AJNR Am J Neuroradiol. 2000; 21(1):74-78. http://www.ajnr.org/content/21/1/74.long.
  7. Bekelis K, Desai A, Zhao W, et al. Computed tomography angiography: Improving diagnostic yield and cost effectiveness in the initial evaluation of spontaneous nonsubarachnoid intracerebral hemorrhage. J Neurosurg. 2012 Oct; 117(4):761-6.
  8. Berlit P, Kraemer M. Cerebral vasculitis in adults: What are the steps in order to establish the diagnosis? Red flags and pitfalls. Clin Exp Immunol. 2014; 175(3):419–424.
  9. Brott TG, Halperin JL, Abbara S, et al. ASA / ACCF / AHA / AANN / AANS / ACR / ASNR / CNS / SAIP / SCAI / SIR / SNIS / SVM / SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: Executive summary. Circulation. 2011; 124:489-532.
  10. Bushnell C, Saposnik G. Evaluation and management of cerebral venous thrombosis. Continuum (Minneap Minn). 2014 Apr; 20(2 Cerebrovascular Disease):335-51.
  11. Chalouhi N, Chitale R, Jabbou P, et al. The case for family screening for intracranial aneurysms. Neurosurg Focus. 2011 Dec; 31(6):E8. http://thejns.org/doi/full/10.3171/2011.9.FOCUS11210.
  12. Chen X, Liu Y, Tong H, et al. Meta-analysis of computed tomography angiography versus magnetic resonance angiography for intracranial aneurysm. Medicine (Baltimore). 2018; 97(20):e10771. doi:10.1097/MD.0000000000010771.
  13. Connors JM, Levy JH. Thromboinflammation and the hypercoagulability of COVID-19. J Thromb Haemost. 2020;18(7):1559-1561. doi:10.1111/jth.14849.
  14. Coutinho JM. Cerebral venous thrombosis. J Thromb Haemost. 2015 Jun; 13 Suppl 1:S238-44.
  15. DaCosta M, Surowiec SM. Carotid Endarterectomy. StatPearls.Treasure Island, FL: StatPearls Publishing; 2019.
  16. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke. 2009 Jun; 40(6):2276-93.
  17. Ferro JM, Bousser M-G, Canhão P, et al. European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis - Endorsed by the European Academy of Neurology. Eur Stroke J. 2017;2(3):195-221. doi:10.1177/2396987317719364.
  18. Ferro JM, Canhão P, Aguiar de Sousa D. Cerebral venous thrombosis. La Presse Med. 2016 Dec; 45(12 Pt 2):e429-e450. Epub 2016 Nov 2.
  19. Franz RW, Willette PA, Wood MJ, et al. A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries. J Am Coll Surg. March 2012; 214(3):313-327.
  20. Godasi R, Bollu PC. Primary central nervous system vasculitis. [Updated 2019 May 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482476/.
  21. Halbach C, McClelland CM, Chen J, Li S, Lee MS. Use of noninvasive imaging in giant cell arteritis. Asia Pac J Ophthalmol (Phila). 2018;7(4):260-264. doi:10.22608/APO.2018133.
  22. Hayes SN, Kim ESH, Saw J, et al. American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Genomic and Precision Medicine; and Stroke Council. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement from the American Heart Association. Circulation. 2018 May 8; 137(19:e523-e557. Epub 2018 Feb 22.
  23. Hitchcock E, Gibson WT. A Review of the Genetics of Intracranial Berry Aneurysms and Implications for Genetic Counseling. J Genet Couns. 2017 Feb; 26(1):21-31. doi: 10.1007/s10897-016-0029-8. Epub 2016 Oct 14.
  24. Hofmann E, Behr R, Neumann-Haefelin T, et al. Pulsatile tinnitus: Imaging and differential diagnosis. Deutsches Ärzteblatt International. 2013; 110(26):451-458. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719451/.
  25. Hong KS, Yegiaian S, Lee M, et al. Declining stroke and vascular event recurrence rates in secondary prevention trials over the past 50 years and consequences for current trial design. Circulation. 2011 May 17; 123(19):2111-9. Epub 2011 May 2.
  26. International Headache Society (IHS). Headache Classification Committee of the International Headache Society (IHS) - The international classification of headache disorders, 3rd edition. Cephalalgia. 2018; 38(1):1–211.
  27. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jul; 45(7):2160-236.
  28. Khan A, Dasgupta B. Imaging in giant cell arteritis. Curr Rheumatol Rep. 2015;17(8):52. doi:10.1007/s11926-015-0527-y.
  29. Koster MJ, Matteson EL, Warrington KJ. Large-vessel giant cell arteritis: Diagnosis, monitoring, and management. Rheumatol. 2018; 57(suppl2):II32-42.
  30. Lafitte F, Boukobza M, Guichard JP, et al. MRI and MRA for diagnosis and follow-up of cerebral venous thrombosis (CVT). Clin Radiol. 1997;52(9):672-679. doi:10.1016/s0009-9260(97)80030-x.
  31. Lawson GR. Sedation of children for magnetic resonance imaging. Archives of Disease in Childhood. 2000; 82(2):150-153. https://adc.bmj.com/content/82/2/150.
  32. Leal PR, Hermier M, Froment JC, et al. Preoperative demonstration of the neurovascular compression characteristics with special emphasis on the degree of compression, using high-resolution magnetic resonance imaging: A prospective study, with comparison to surgical findings, in 100 consecutive patients who underwent microvascular decompression for trigeminal neuralgia. Acta Neurochir (Wien). 2010 May; 152(5):817-25.
  33. Lee CC, Reardon MA, Ball BZ, et al. The predictive value of magnetic resonance imaging in evaluating intracranial arteriovenous malformation obliteration after stereotactic radiosurgery. J Neurosurg. 2015 Jul; 123(1):136-44. doi: 10.3171/2014.10.JNS141565. Epub 2015 Apr 3.
  34. Lee M, Kim MS. Image findings in brain developmental venous anomalies. J Cerebrovasc Endovasc Neurosurg. 2012 Mar; 14(1):37-43. doi: 10.7461/jcen.2012.14.1.37. Epub 2012 Mar 31.
  35. Liang T, Tso DK, Chiu RY, et al. Imaging of blunt vascular neck injuries: A review of screening and imaging modalities. AJR Am J Roentgenol. 2013 Oct; 201(4):884-92.
  36. Lima Neto AC, Bittar R, Gattas GS, et al. pathophysiology and diagnosis of vertebrobasilar insufficiency: A review of the literature. Int Arch Otorhinolaryngol. 2017; 21(3):302–307.
  37. Macaya F, Moreu M, Ruiz-Pizarro V, et al. Screening of extra-coronary arteriopathy with magnetic resonance angiography in patients with spontaneous coronary artery dissection: A single-centre experience. Cardiovasc Diagn Ther. 2019 Jun; 9(3:229-238.
  38. Marquardt L, Geraghty OC, Mehta Z, et al. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: A prospective, population-based study. Stroke. 2010; 41(1):e11.
  39. Morrison L, Akers A. Cerebral cavernous malformation, familial. In: Adam MP, Ardinger HH, Pagon RA, et al., eds. GeneReviews®. University of Washington, Seattle; 1993. [Updated 2016 Aug 4]. Accessed August 17, 2021. http://www.ncbi.nlm.nih.gov/books/NBK1293/.
  40. Mundinger GS, Dorafshar AH, Gilson MM, et al. Blunt-mechanism facial fracture patterns associated with internal carotid artery injuries: recommendations for additional screening criteria based on analysis of 4,398 patients. J Oral Maxillofac Surg. December 2013; 71(12):2092-2100.
  41. Nash M, Rafay MF. Craniocervical Arterial Dissection in Children: Pathophysiology and Management. Pediatr Neurol. 2019 Jun; 95:9-18. doi:10.1016/j.pediatrneurol.2019.01.020. Epub 2019 Feb 2.
  42. Obusez EC, Hui F, Hajj-Ali RA, et al. High-resolution MRI vessel wall imaging: spatial and temporal patterns of reversible cerebral vasoconstriction syndrome and central nervous system vasculitis. AJNR Am J Neuroradiol. 2014; 35(8): 1527-1532. http://www.ajnr.org/content/early/2014/04/10/ajnr.A3909.full.pdf.
  43. Pegge SAH, Steens SCA, Kunst HPM, et al. Pulsatile tinnitus: Differential diagnosis and radiological work-up. Curr Radiol Rep. 2017; 5(1):5.
  44. Pirau L, Lui F. Vertebrobasilar Insufficiency. [Updated 2019 Mar 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482259/.
  45. Pula JH, Kwan K, Yuen CA, Kattah JC. Update on the evaluation of transient vision loss. Clin Ophthalmol. 2016; 10:297–303. Published 2016 Feb 11.
  46. Rerkasem K, Rothwell PM. Carotid endarterectomy for symptomatic carotid stenosis. Cochrane Database Syst Rev. 2011.
  47. Robertson RL, Palasis S, Rivkin MJ, et al. ACR Appropriateness Criteria® Cerebrovascular Disease-Child. J Am Coll Radiol. 2020;17(5S):S36-S54. doi:10.1016/j.jacr.2020.01.036.
  48. Sacco RL, Kasner SE, Broderick JP, et al. An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013 Jul; 44(7):2064-89.
  49. Salmela MB, Mortazavi S, Jagadeesan BD, et al. ACR Appropriateness Criteria ® Cerebrovascular Disease. J Am Coll Radiol. 2017;14(5S):S34-S61. doi:10.1016/j.jacr.2017.01.051.
  50. Sanelli PC, Sykesa JB, Ford AL, et al. Imaging and treatment of patients with acute stroke: An evidence-based review. AJNR Am J Neuroradiol. 2014; 35:1045-1051. http://www.ajnr.org/content/35/6/1045.full.
  51. Saposnik G, Barinagarrementeria F, Brown RD, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42(4):1158-1192. doi:10.1161/STR.0b013e31820a8364.
  52. Searls DE, Pazdera L, Korbel E, et al. Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol. 2012; 69(3):346.
  53. Serafin Z, Strześniewski P, Lasek W, et al. Follow-up after embolization of ruptured intracranial aneurysms: A prospective comparison of two-dimensional digital subtraction angiography, three-dimensional digital subtraction angiography, and time-of-flight magnetic resonance angiography. Neuroradiol. 2012 Nov; 54(11):1253-60. Epub 2012 Apr 10.
  54. Shakir HJ, Davies JM, Shallwani H, Siddiqui AH, Levy EI. Carotid and Vertebral Dissection Imaging. Curr Pain Headache Rep. 2016 Dec; 20(12:68.
  55. Simon LV, Mohseni M. Vertebral Artery Injury. StatPearls. Treasure Island, FL: StatPearls Publishing; 2019. https://www.ncbi.nlm.nih.gov/books/NBK470363/.
  56. Singhal AU, Topcuoglu MA, Fok JW, et al. Reversible cerebral vasoconstriction syndromes and primary angiitis of the central nervous system: Clinical, imaging, and angiographic comparison. Ann Neurol. 2016 Jun; 79(6):882-94. Epub 2016 Apr 28.
  57. Tarasów E, Kułakowska A, Lukasiewicz A, et al. Moyamoya disease: Diagnostic imaging. Pol J Radiol. 2011; 76(1):73–79.
  58. Thust SC, Burke C, Siddiqui A. Neuroimaging findings in sickle cell disease. Br J Radiol. 2014; 87(1040):20130699. doi:10.1259/bjr.20130699.
  59. Tu TM, Goh C, Tan YK, et al. Cerebral venous thrombosis in patients with COVID-19 infection: a case series and systematic review. J Stroke Cerebrovasc Dis. 2020;29(12):105379. doi:10.1016/j.jstrokecerebrovasdis.2020.105379.
  60. Whitehead MT, Cardenas AM, Corey AS, et al. ACR Appropriateness Criteria® - Headache. J Am Coll Radiol. 2019; 16:S364-S377.
  61. Wintermark M, Sanelli PC, Albers GW, et al. Imaging recommendations for acute stroke and transient ischemic attack patients: A joint statement by the American Society of Neuroradiology, the AmericanCollege of Radiology, and the Society of NeuroInterventional Surgery. AJNR Am J Neuroradiol. 2013 Nov-Dec; 34(11):E117-27. Epub 2013 Aug 1.
  62. Xu HW, Yu SQ, Mei CL, Li MH. Screening for intracranial aneurysm in 355 patients with autosomal-dominant polycystic kidney disease. Stroke. 2011;42(1):204-206. doi:10.1161/STROKEAHA.110.578740.
  63. Yeh YC, Fuh JL, Chen SP, et al. Clinical features, imaging findings and outcomes of headache associated with sexual activity. Cephalalgia. 2010 Nov; 30(11):1329-35.
  64. Yuan MK, Lai PH, Chen JY, et al. Detection of subarachnoid hemorrhage at acute and subacute/chronic stages: Comparison of four magnetic resonance imaging pulse sequences and computed tomography. J Chin Med Assoc. 2005 Mar; 68(3):131-7.
  65. Zuccoli G, Pipitone N, Haldipur A, et al. Imaging findings in primary central nervous system vasculitis. [Published online ahead of print May 11, 2011]. Clin Exp Rheumatol. 2011; 29(1 Suppl 64):S104-109.
  66. Zyck S, Gould GC. Cavernous venous malformation. In: StatPearls. StatPearls Publishing; 2021. Accessed August 16, 2021. http://www.ncbi.nlm.nih.gov/books/NBK526009/.

Coding Section 

Code Number Description
CPT 70544 MR (Magnetic Resonance Imaging) Angiography Brain without contrast)  
  70545 MR (Magnetic Resonance Imaging) Angiography Brain with contrast) 
  70546 MR (Magnetic Resonance Imaging) Angiography Brain without and with contrast) 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2020 Forward     

11/04/2021 

Annual review, adding medical necessity statement related to headache associated with exercise or sexual activity, giant cell arteritis and preoperative evaluation. Also updating description and references. 

01/01/2021

New Policy

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