Seizures and Epilepsy

Variant: 1 New-onset seizure. Unrelated to trauma. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
MRI head without and with IV contrast	May Be Appropriate	O
MEG	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
SPECT or SPECT/CT brain perfusion ictal and interictal	Usually Not Appropriate	☢☢☢

Variant: 2 New-onset seizure. History of trauma. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
CT head without IV contrast	Usually Appropriate	☢☢☢
MRI head without and with IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MEG	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT brain	Usually Not Appropriate	☢☢☢
SPECT or SPECT/CT brain perfusion ictal and interictal	Usually Not Appropriate	☢☢☢

Variant: 3 Known seizure disorder. Unchanged seizure semiology.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate (Disagreement)	O
CT head without IV contrast	May Be Appropriate	☢☢☢
FDG-PET/CT brain	May Be Appropriate (Disagreement)	☢☢☢
MEG	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
SPECT or SPECT/CT brain perfusion ictal and interictal	Usually Not Appropriate	☢☢☢

Variant: 4 Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
FDG-PET/CT brain	May Be Appropriate	☢☢☢
MEG	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
SPECT or SPECT/CT brain perfusion ictal and interictal	Usually Not Appropriate	☢☢☢

Variant: 5 Known seizure disorder. History of tumor.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without and with IV contrast	May Be Appropriate (Disagreement)	☢☢☢
CT head without IV contrast	May Be Appropriate	☢☢☢
FDG-PET/CT brain	May Be Appropriate (Disagreement)	☢☢☢
MEG	Usually Not Appropriate	O
MRI functional (fMRI) head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
SPECT or SPECT/CT brain perfusion ictal and interictal	Usually Not Appropriate	☢☢☢

Variant: 6 Known seizure disorder. Surgical candidate or surgical planning.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
FDG-PET/CT brain	Usually Appropriate	☢☢☢
MEG	May Be Appropriate	O
MRI functional (fMRI) head without IV contrast	May Be Appropriate	O
CT head with IV contrast	May Be Appropriate	☢☢☢
CT head without IV contrast	May Be Appropriate	☢☢☢
SPECT or SPECT/CT brain perfusion ictal and interictal	May Be Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢

Panel Members

Ryan K. Lee, ^a; Judah Burns, MD^b; Amna A. Ajam, MD, MBBS^c; Joshua S. Broder, MD^d; Santanu Chakraborty, MBBS, MSc^e; Suzanne Chong, ^f; A. Tuba Karagulle Kendi, MD^g; Luke N. Ledbetter, MD^h; David S. Liebeskind, MDⁱ; Jeffrey S. Pannell, MD^j; Jeffrey M. Pollock, MD^k; Joshua M. Rosenow, MD^l; Matthew D. Shaines, MD^m; Robert Y. Shih, MDⁿ; Konstantin Slavin, MD^o; Pallavi S. Utukuri, MD^p; Amanda S. Corey, MD^q.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Discussion of Procedures by Variant

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.
A. CT Head

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.
B. FDG-PET/CT Brain

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.
C. MEG

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.
D. MRI Functional (fMRI) Head

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.
E. MRI Head

Variant 1: New-onset seizure. Unrelated to trauma. Initial imaging.
F. HMPAO SPECT or SPECT/CT Brain Ictal and Interictal

Variant 2: New-onset seizure. History of trauma. Initial imaging.

Variant 2: New-onset seizure. History of trauma. Initial imaging.
A. CT Head

Variant 2: New-onset seizure. History of trauma. Initial imaging.
B. FDG-PET/CT Brain

Variant 2: New-onset seizure. History of trauma. Initial imaging.
C. MEG

Variant 2: New-onset seizure. History of trauma. Initial imaging.
D. MRI Functional (fMRI) Head

Variant 2: New-onset seizure. History of trauma. Initial imaging.
E. MRI Head

Variant 2: New-onset seizure. History of trauma. Initial imaging.
F. HMPAO SPECT or SPECT/CT Brain Ictal and Interictal

Variant 3: Known seizure disorder. Unchanged seizure semiology.

Variant 3: Known seizure disorder. Unchanged seizure semiology.
A. CT Head

Variant 3: Known seizure disorder. Unchanged seizure semiology.
B. FDG-PET/CT Brain

Variant 3: Known seizure disorder. Unchanged seizure semiology.
C. MEG

Variant 3: Known seizure disorder. Unchanged seizure semiology.
D. MRI Functional (fMRI) Head

Variant 3: Known seizure disorder. Unchanged seizure semiology.
E. MRI Head

Variant 3: Known seizure disorder. Unchanged seizure semiology.
F. HMPAO SPECT or SPECT/CT Brain Ictal and Interictal

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.
A. CT Head

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.
B. FDG-PET/CT Brain

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.
C. MEG

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.
D. MRI Functional (fMRI) Head

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.
E. MRI Head

Variant 4: Known seizure disorder. Change in seizure semiology or new neurologic deficit or no return to previous neurologic baseline.
F. HMPAO SPECT or SPECT/CT Brain Ictal and Interictal

Variant 5: Known seizure disorder. History of tumor.

Variant 5: Known seizure disorder. History of tumor.
A. CT Head

Variant 5: Known seizure disorder. History of tumor.
B. FDG-PET/CT Brain

Variant 5: Known seizure disorder. History of tumor.
C. MEG

Variant 5: Known seizure disorder. History of tumor.
D. MRI Functional (fMRI) Head

Variant 5: Known seizure disorder. History of tumor.
E. MRI Head

Variant 5: Known seizure disorder. History of tumor.
F. HMPAO SPECT or SPECT/CT Brain Ictal and Interictal

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.
A. CT Head

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.
B. FDG-PET/CT Brain

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.
C. MEG

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.
D. MRI Functional (fMRI) Head

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.
E. MRI Head

Variant 6: Known seizure disorder. Surgical candidate or surgical planning.
F. HMPAO SPECT or SPECT/CT Brain Ictal and Interictal

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.