Discussion

This case is a prime example of the importance of using physical diagnosis before any adjunctive techniques. The patient had seen several doctors before and none could reason out her condition. However, after auscultating her right retroaural region, the bruit was extremely distinct and pathognomonic for pulsatile tinnitus, mostly likely secondary to some sort of anatomical vascular issue. So clear, in fact, that even a medical student could discern something was amiss. This further emphasises the importance of utilising basic techniques such as auscultation, palpation and others. After performing a thorough physical exam, we reasoned that additional techniques such as MRI, MRA and MRV were necessary to further the diagnosis so the patient could receive the best care possible.

Before metals and electronics, a physician’s diagnosis was based solely on history and what they could feel with their hands. According to Roguin,3 centuries later the stethoscope was invented by Laënnec in 1816. Since then, it has become one of the hallmark symbols of medicine. Every physician is taught to use this instrument, and as a result needs to actually examine the patient himself or herself. Since then, there has been an explosion of technological development in the field of medicine. All of it is extremely beneficial, but it has driven physicians to rely on what technology perceives rather than their own senses.

For instance, the MRI. Since its invention, it has rapidly risen to become a staple imaging and diagnostic technique in many fields of medicine. The beginnings of MRI stemmed from Bloch and Purcell, the winners of the 1952 Nobel Prize in Physics,4 for their novel methods of using nuclear magnetic resonance (NMR) spectroscopy for precision measurements. Later on, Damadian5 tweaked the concept on NMR after scanning tumour tissue, noticed it had a prolonged T1 relaxation time compared with normal tissue. Damadian et al6 would then go on to perform the first full body scan using magnetic resonance technology in 1977. A few years later, the MRI would be further improved both in practicality and functionality. Lauterbur7 was able to combine a series of rotating one-dimensional NMR images into one 2D or 3D image. Ordidge et al8 9 tempered the technique by inventing ‘slice selection’ and developed the MRI protocol called ‘echo-planar imaging’, making functional MRI more feasible.

Another popular imaging modality is angiography. Early trailblazers in angiography10 focused on developing fluoroscopy and radiography techniques while studying cardiac diseases from 1899 to 1902. Tan and Yip cite Monize11 as the first to use the technique in 1927 for contrasted X-ray cerebral angiography to diagnose nervous diseases such as tumours and arteriovenous malformations. From there, angiography further evolved through the efforts of Forsmann12 in 1929 with his attempts at cardiac catheterisation and angiocardiography. These advances paved the way for many clinicians to continue honing the technique during the 1930s and 1940s. In 1941, Cournand13 demonstrated that cardiac catheterisation was safe to use on the human body. As the years rolled on, more advances such as rapid filming, demonstration of coronary anatomy and balloon angioplasty came into being.

With the inception of both the MRI and angiography, physicians began to use these techniques more and more, eventually merging both into MRA and MRV.14 15 However, there were two large issues that made MRA and MRV techniques suboptimal procedures in many situations: the inability to produce simultaneous bilateral images and the long time it took to produce images. Then, during 2003 and then 2004, the advent of parallel imaging coupled with new pulse sequences16 reduced the total time of imaging by one-third to half the original time.

In the present, due to their wide availability, modern physicians oftentimes overuse imaging techniques. Hawasli et al17 state that headaches consist of 1.5% of all chief complaints in a primary care setting. Irrespective of many neuroimaging guidelines, expenditures for neuroimaging of headaches and migraines in the USA reached nearly US$1.2 billion. This exorbitant cost is attributed to the practice of ‘defensive medicine’, which results in neuroimaging solely done to reduce malpractice liability and medical errors. It has been shown that discovery of certain diseases earlier, such as brain tumours, improves outcomes. Moreover, with certain criteria such as the Choosing Wisely guidelines, false-negatives have been shown to be anywhere from 3% to 7%. However, even taking these facts into account, this is not an excuse for performing a haphazard history and physical, and skip directly to neuroimaging.

There is no universally accepted guideline for neuroimaging, especially for headaches. A physician must exercise excellent clinical judgement in order to reduce the amount of unnecessary neuroimaging.

MRIs are notoriously overused. They do not use ionising radiation, which decreases risks of stochastic effects, have better soft tissue resolution, and the contrast agents have less risk of allergic reactions when compared with CTs.18 19

In the case above, the positive finding of pulsatile tinnitus was an indication for use of MRI/MRA rather than starting with CT angiography. Moreover, the neurovascular surgeon requested an MRI/MRA, so regardless of the findings on CT the former would be needed regardless. Given the patient’s physical exam findings and rather than subjecting the patient to two procedures, we decided to expedite the process by skipping the CT.

It is important to remember that patient disposition ought to be contingent on performing a comprehensive exam. Cultivating a conscientious style of medicine would lead towards improved clinical judgement and yield less expenditures and better quality of healthcare overall.