Incidentalomas: You can hate them but can’t ignore them

We order a lot of MRIs. Patients, in general, want a lot of MRIs (as long as insurance covers them). We have all this cool technology, so why not use it?

For the most part we’re doing them to rule-out bad things such as gliomas and ginormous aneurysms so we can say: “It looks fine, so I think you’re just having headaches/migraines/anxiety attacks, whatever.”

Unfortunately, as technology improves, we end up with a whole new issue that previous generations of neurologists didn’t have to deal with: the hated incidentaloma. And, often, this can be insanely frustrating. Just because an abnormality isn’t related to the symptoms doesn’t mean you can forget about it, either.

It’s amazing how many scans come back with small meningiomas, aneurysms, microadenomas, etc. Once you find them, you (and the patient) are stuck with it.

I usually try to downplay these findings, as they’re typically irrelevant. But, even then, you’re now obligated to repeat the scans every 1-5 years (depending on what you found) to make sure the thingamajig is stable. Which only drives up costs for the patient and their insurance.

Then there’s the aspect of how the patient sees this. Most are perfectly fine when you explain it to them, but you get some who are panicked (“OMG! I have a brain tumor!”) and require quite a bit of time to calm down.

There are others who latch onto it, and insist, against all rational evidence, that it’s the sole cause of their symptoms. They will often call at 2:00 a.m. for the slightest change in their symptoms or just go straight to an emergency department “because I have an aneurysm.” Trying to get them to accept that the finding is incidental is often a challenge, with them often seeking multiple other opinions.

In the best case, though, the finding is a nuisance to all involved. I have to enter that patient in my scheduled reminders to order a follow-up study. If they don’t respond to a phone call, or regular letter, I have to send them a certified letter. From their view they have to work another MRI into what’s probably a busy schedule. Depending on their deductible, they may have to pay a decent amount of money for it. And then it may add paperwork next time they apply for life insurance.

What’s to be done for it? Nothing that I can think of. If we don’t pursue the testing, we become legally liable if the lesion grows. The patient could decline it, but most don’t. And, as scans improve, the number of incidentalomas will increase.

The revolution that MRI has brought to neurology can’t be understated. But, at the same time, it has its drawbacks. For both patients and neurologists, dealing with the incidentals and their consequences is one of them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

We order a lot of MRIs. Patients, in general, want a lot of MRIs (as long as insurance covers them). We have all this cool technology, so why not use it?

For the most part we’re doing them to rule-out bad things such as gliomas and ginormous aneurysms so we can say: “It looks fine, so I think you’re just having headaches/migraines/anxiety attacks, whatever.”

Unfortunately, as technology improves, we end up with a whole new issue that previous generations of neurologists didn’t have to deal with: the hated incidentaloma. And, often, this can be insanely frustrating. Just because an abnormality isn’t related to the symptoms doesn’t mean you can forget about it, either.

It’s amazing how many scans come back with small meningiomas, aneurysms, microadenomas, etc. Once you find them, you (and the patient) are stuck with it.

I usually try to downplay these findings, as they’re typically irrelevant. But, even then, you’re now obligated to repeat the scans every 1-5 years (depending on what you found) to make sure the thingamajig is stable. Which only drives up costs for the patient and their insurance.

Then there’s the aspect of how the patient sees this. Most are perfectly fine when you explain it to them, but you get some who are panicked (“OMG! I have a brain tumor!”) and require quite a bit of time to calm down.

There are others who latch onto it, and insist, against all rational evidence, that it’s the sole cause of their symptoms. They will often call at 2:00 a.m. for the slightest change in their symptoms or just go straight to an emergency department “because I have an aneurysm.” Trying to get them to accept that the finding is incidental is often a challenge, with them often seeking multiple other opinions.

In the best case, though, the finding is a nuisance to all involved. I have to enter that patient in my scheduled reminders to order a follow-up study. If they don’t respond to a phone call, or regular letter, I have to send them a certified letter. From their view they have to work another MRI into what’s probably a busy schedule. Depending on their deductible, they may have to pay a decent amount of money for it. And then it may add paperwork next time they apply for life insurance.

What’s to be done for it? Nothing that I can think of. If we don’t pursue the testing, we become legally liable if the lesion grows. The patient could decline it, but most don’t. And, as scans improve, the number of incidentalomas will increase.

The revolution that MRI has brought to neurology can’t be understated. But, at the same time, it has its drawbacks. For both patients and neurologists, dealing with the incidentals and their consequences is one of them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

We order a lot of MRIs. Patients, in general, want a lot of MRIs (as long as insurance covers them). We have all this cool technology, so why not use it?

For the most part we’re doing them to rule-out bad things such as gliomas and ginormous aneurysms so we can say: “It looks fine, so I think you’re just having headaches/migraines/anxiety attacks, whatever.”

Unfortunately, as technology improves, we end up with a whole new issue that previous generations of neurologists didn’t have to deal with: the hated incidentaloma. And, often, this can be insanely frustrating. Just because an abnormality isn’t related to the symptoms doesn’t mean you can forget about it, either.

It’s amazing how many scans come back with small meningiomas, aneurysms, microadenomas, etc. Once you find them, you (and the patient) are stuck with it.

I usually try to downplay these findings, as they’re typically irrelevant. But, even then, you’re now obligated to repeat the scans every 1-5 years (depending on what you found) to make sure the thingamajig is stable. Which only drives up costs for the patient and their insurance.

Then there’s the aspect of how the patient sees this. Most are perfectly fine when you explain it to them, but you get some who are panicked (“OMG! I have a brain tumor!”) and require quite a bit of time to calm down.

There are others who latch onto it, and insist, against all rational evidence, that it’s the sole cause of their symptoms. They will often call at 2:00 a.m. for the slightest change in their symptoms or just go straight to an emergency department “because I have an aneurysm.” Trying to get them to accept that the finding is incidental is often a challenge, with them often seeking multiple other opinions.

In the best case, though, the finding is a nuisance to all involved. I have to enter that patient in my scheduled reminders to order a follow-up study. If they don’t respond to a phone call, or regular letter, I have to send them a certified letter. From their view they have to work another MRI into what’s probably a busy schedule. Depending on their deductible, they may have to pay a decent amount of money for it. And then it may add paperwork next time they apply for life insurance.

What’s to be done for it? Nothing that I can think of. If we don’t pursue the testing, we become legally liable if the lesion grows. The patient could decline it, but most don’t. And, as scans improve, the number of incidentalomas will increase.

The revolution that MRI has brought to neurology can’t be understated. But, at the same time, it has its drawbacks. For both patients and neurologists, dealing with the incidentals and their consequences is one of them.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.