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    Imaging for Horner syndrome: Balancing cost with diagnostic accuracy

    A three-step protocol appears similar, less expensive than previously reported protocols


    Comparison with other protocols

    Chen compared the study under discussion with four imaging recommendations.

    The first study by Davagnanam and colleagues (Eye. 2013;27:291-298) recommended that any imaging performed be based on neuronal localization, i.e., MRI for first-order neuronal locations and CTA for second- and third-order localization. In cases with no localizing signs or with an acute onset, they recommended that CTA be performed within 6 weeks. The costs reported in association with this approach were similar to the study of Chen and associates.

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    A second study, that of Reede et al. (Neuroimag Clin N Am. 2008;18:369-385) recommended that pharmacologic localization be carried out first. The imaging protocol was the same as the one in the study of Davagnanam et al., with the exception that no imaging was done for third-order neuronal localization. The costs were similar to those discussed previously.

    In the third study, Lee et al. (AJR. 2007;188:W74-W81) recommended that imaging should be based on a suspected etiology and not pharmacologic localization. These authors used CT to identify suspected lesions in the lungs, mediastinum, and neck and MRI for lesions in the brachial plexus or cervical spinal cord. In cases of postganglionic Horner syndrome, no imaging recommendation was provided. The costs were less than those reported in the previous studies.

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    In the final study of 52 patients reported by Almog and coworkers (J Neuro-Ophthalmol. 2010;30:7-11), the imaging recommendations were based on examinations without specific etiologies (i.e., MRI of the head and neck and CT or MRI of the chest). For those cases with etiologies, MRI or CT was performed as appropriate. The costs reported in this study were higher than in Chen’s study because of the added MRI and CT images of the chest.

    Making a recommendation

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