Imaging for Horner syndrome: Balancing cost with diagnostic accuracy
A single contrast-enhanced brain magnetic resonance imaging extending to the level of T2 in the chest and pharmacologic confirmation without localization seems appropriate to identify lesions in patients with Horner syndrome.
Reviewed by Ying Chen, BS, and Andrew G. Lee, MD
Houston-While Horner syndrome itself is uncommon, the life-threatening aspect of the condition demands immediate attention when a patient presents acutely with ipsilateral miosis, ptosis, and anhidrosis resulting from a lesion in the oculosympathetic pathway.
However, there is no current consensus on the best way to ferret out the underlying etiology.
The conventional approach to evaluating a patient with Horner syndrome has been a clinical and pharmacologic assessment with localization of the lesion. Multimodal testing can be the last step in the process, but searches of the current literature show literature lack of consensus on the type of imaging as well as its cost and diagnostic yield, according to Ying Chen, BS.
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To discern the importance of imaging in this patient population, Chen designed a study to determine the efficacy, safety, and cost-effectiveness of an imaging protocol. Chen is a medical student going into ophthalmology who will be graduating from Baylor College of Medicine, Houston.
Chen and her associates evaluated patients with Horner syndrome with a single contrast-enhanced head and neck magnetic resonance imaging (MRI) that extending to the thoracic T2 level. The investigators then compared this protocol with others already published.
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They first retrospectively reviewed all patients who received a causative or idiopathic diagnosis of Horner syndrome in their institution between 2010 and 2013. All patients underwent a single contrast-enhanced MRI of the brain that extended to T2.
However, in acute cases, the patients underwent computed tomography (CT) or CT angiography (CTA) of the head and neck. The investigators then evaluated the efficacy and cost-effectiveness of this method, Chen noted.
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She reported that of the 34 patients identified with Horner syndrome, 27 were included in the study. In 11 patients the Horner syndrome was secondary to a proven cause, and in 16 patients no cause was identified. The cost of this protocol based on Medicare reimbursements in 2014 was estimated to be $667.76 without magnetic resonance angiography (MRA) and $1,501.71 with MRA.
The investigators published their findings (Canadian Journal of Ophthalmology. 2015;50:107-111).
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