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Appropriateness Criteria

Variant 1: Acute head trauma, mild (GCS 13–15), imaging not indicated by clinical decision rule. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 1 0 0 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 2 1 0 0 0 0 0
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 1 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
References Study Quality
9 (10891517) 3
10 (11356436) 3
4 (16189365) 3
11 (16189364) 2
8 (20093524) 3
13 (21563330) 4
15 (19027497) 4
12 (29753518) 1
7 (21835403) 4
14 (30065073) 4
3 (32370957) 4
CT head without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 3 0 0 0 0 0 0 0
References Study Quality
9 (10891517) 3
10 (11356436) 3
4 (16189365) 3
11 (16189364) 2
8 (20093524) 3
13 (21563330) 4
15 (19027497) 4
12 (29753518) 1
7 (21835403) 4
14 (30065073) 4
3 (32370957) 4
CT head without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 8 4 2 5 0 0 0 0 0
References Study Quality
9 (10891517) 3
10 (11356436) 3
4 (16189365) 3
11 (16189364) 2
8 (20093524) 3
13 (21563330) 4
15 (19027497) 4
12 (29753518) 1
7 (21835403) 4
14 (30065073) 4
3 (32370957) 4
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
Variant 2: Acute head trauma, mild (GCS 13-15), imaging indicated by clinical decision rule. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT head without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 0 1 0 5 1 12
References Study Quality
17 (19809839) 2
19 (1404507) 3
2 (25456317) 4
16 (19797789) 3
18 (26176603) 4
22 (29452747) 2
27 (30054151) 2
24 (31081856) 2
20 (19306376) 4
28 (23102492) 2
23 (30447947) 2
25 (30485240) 4
7 (21835403) 4
26 (29690824) 2
29 (26607648) 1
21 (30643942) 4
5 (30547708) 4
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 18 0 0 1 0 0 0 0 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 1 0 0 0 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 1 1 0 0 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 1 0 0 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 2 0 1 0 0 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 1 0 0 0 0 0 0 0
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 1 0 1 0 0 0
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 1 2 0 0 0 0 0
References Study Quality
17 (19809839) 2
19 (1404507) 3
2 (25456317) 4
16 (19797789) 3
18 (26176603) 4
22 (29452747) 2
27 (30054151) 2
24 (31081856) 2
20 (19306376) 4
28 (23102492) 2
23 (30447947) 2
25 (30485240) 4
7 (21835403) 4
26 (29690824) 2
29 (26607648) 1
21 (30643942) 4
5 (30547708) 4
CT head without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 4 1 1 0 0 0 0 0
References Study Quality
17 (19809839) 2
19 (1404507) 3
2 (25456317) 4
16 (19797789) 3
18 (26176603) 4
22 (29452747) 2
27 (30054151) 2
24 (31081856) 2
20 (19306376) 4
28 (23102492) 2
23 (30447947) 2
25 (30485240) 4
7 (21835403) 4
26 (29690824) 2
29 (26607648) 1
21 (30643942) 4
5 (30547708) 4
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 1 0 2 0 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
Variant 3: Acute head trauma, moderate (GCS 9–12) or severe (GCS 3–8), or penetrating. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT head without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 0 0 1 0 1 17
References Study Quality
17 (19809839) 2
31 (1535893) 2
16 (19797789) 3
32 (20815050) 4
30 (28091809) 4
33 (31490891) 2
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 1 0 0 0 0 1 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 2 1 1 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 1 0 1 1 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 0 2 1 1 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 2 0 1 0 1 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 0 1 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 1 1 1 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 0 0 4 0 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 0 2 0 0 1 0
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 3 0 1 3 0 0 0 0
References Study Quality
17 (19809839) 2
31 (1535893) 2
16 (19797789) 3
32 (20815050) 4
30 (28091809) 4
33 (31490891) 2
CT head without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 1 2 1 1 0 0 0
References Study Quality
17 (19809839) 2
31 (1535893) 2
16 (19797789) 3
32 (20815050) 4
30 (28091809) 4
33 (31490891) 2
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 3 1 0 0 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
Variant 4: Acute head trauma with unchanged neurologic examination and unremarkable initial imaging. Short-term follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 5 11 3 0 0 0
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
7 (21835403) 4
29 (26607648) 1
39 (31451409) 2
CT head without IV contrast May be appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 1 2 5 9 1 0 0 0
References Study Quality
2 (25456317) 4
13 (21563330) 4
35 (29450470) 2
7 (21835403) 4
34 (24810669) 4
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 1 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 2 0 0 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 2 0 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 2 0 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 15 1 1 0 1 0 0 0 0
References Study Quality
38 (23224915) 2
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
18 (26176603) 4
29 (26607648) 1
39 (31451409) 2
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 1 1 1 3 0 0 0 0
References Study Quality
38 (23224915) 2
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
18 (26176603) 4
29 (26607648) 1
39 (31451409) 2
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 0 1 1 0 0 1
CT head with IV contrast Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 2 0 0 0 0 0 0
References Study Quality
2 (25456317) 4
13 (21563330) 4
35 (29450470) 2
7 (21835403) 4
34 (24810669) 4
CT head without and with IV contrast Usually not appropriate Moderate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 1 1 0 0 0 0 0
References Study Quality
2 (25456317) 4
13 (21563330) 4
35 (29450470) 2
7 (21835403) 4
34 (24810669) 4
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 1 1 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
Variant 5: Acute head trauma with unchanged neurologic examination and positive finding(s) on initial imaging (eg, subdural hematoma). Short-term follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 0 0 0 4 2 10 2 1
References Study Quality
40 (23914924) M
41 (24401514) 4
2 (25456317) 4
42 (22196096) 4
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 0 0 4 11 3 1 0 0
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
18 (26176603) 4
29 (26607648) 1
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 1
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 1 1 1 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 1 0 0 0 0 0 0
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 1 0 1 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 2 2 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 0 1 1 2 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 1 0 0 0 0
MRI head with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 1 1 1 0 0 0 1 0
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
18 (26176603) 4
29 (26607648) 1
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 12 0 1 2 1 1 0 1 0
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
18 (26176603) 4
29 (26607648) 1
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 2 0 0 1 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 1 0 1 0 0 0 0
References Study Quality
40 (23914924) M
41 (24401514) 4
2 (25456317) 4
42 (22196096) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 1 1 0 0 0
References Study Quality
40 (23914924) M
41 (24401514) 4
2 (25456317) 4
42 (22196096) 4
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 1 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 1 0 0 0 0
Variant 6: Acute head trauma with new or progressive neurologic deficit(s). Short-term follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT head without IV contrast Usually appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 0 0 0 0 4 14
References Study Quality
17 (19809839) 2
2 (25456317) 4
16 (19797789) 3
42 (22196096) 4
35 (29450470) 2
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 2 6 3 4 2 1
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
29 (26607648) 1
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 1 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 2 0 1 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 1 0 0 0 0 0
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 1 1 0 0 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 3 2 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 0 3 1 1 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 1 0 0 0 0
MRI head with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 14 1 1 1 0 0 1 0 0
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
29 (26607648) 1
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 9 0 3 0 4 1 1 0 0
References Study Quality
36 (9798776) 3
2 (25456317) 4
37 (19359907) 2
29 (26607648) 1
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 1 1 0 0 1
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 0 1 2 0 0 1 0 0
References Study Quality
17 (19809839) 2
2 (25456317) 4
16 (19797789) 3
42 (22196096) 4
35 (29450470) 2
CT head without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 1 0 4 0 1 0 0
References Study Quality
17 (19809839) 2
2 (25456317) 4
16 (19797789) 3
42 (22196096) 4
35 (29450470) 2
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 0 0 4 1 1 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 1 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 0 0 0 1 0 0 0 0
Variant 7: Subacute or chronic head trauma with unexplained cognitive or neurologic deficit(s). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 1 0 0 0 0 1 2 1 13
References Study Quality
38 (23224915) 2
52 (9635948) 2
51 (19852541) 2
50 (24740482) 4
18 (26176603) 4
32 (20815050) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 0 0 0 1 3 12 0 3
References Study Quality
32 (20815050) 4
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 1 0 0 1 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 7 6 1 0 3 1 0 0 0
References Study Quality
45 (25424870) 4
18 (26176603) 4
46 (24417798) 2
32 (20815050) 4
MRA head and neck with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 1 0 0 1 0 0
MRA head and neck without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 0 1 3 1 0 0 0
MRA head and neck without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 0 1 2 2 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 4 2 1 3 1 1 0 0
References Study Quality
45 (25424870) 4
47 (20611044) 4
18 (26176603) 4
48 (28085565) 4
49 (31210098) 4
MRI head with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 11 1 2 2 0 0 1 1 0
References Study Quality
38 (23224915) 2
52 (9635948) 2
51 (19852541) 2
50 (24740482) 4
18 (26176603) 4
32 (20815050) 4
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 13 1 2 2 1 0 0 0 0
References Study Quality
38 (23224915) 2
52 (9635948) 2
51 (19852541) 2
50 (24740482) 4
18 (26176603) 4
32 (20815050) 4
MRI head without IV contrast with DTI Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 12 3 2 1 0 0 0 0 1
References Study Quality
45 (25424870) 4
54 (20089939) 3
18 (26176603) 4
53 (29878909) 4
55 (27282864) 1
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 13 3 1 1 0 0 0 0 0
References Study Quality
32 (20815050) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 2 0 1 0 0 0 0
References Study Quality
32 (20815050) 4
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
FDG-PET/CT brain Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 4 3 0 4 1 1 0 0
References Study Quality
45 (25424870) 4
44 (20385245) 4
18 (26176603) 4
32 (20815050) 4
SPECT or SPECT/CT brain perfusion Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 4 3 0 4 1 1 0 0
References Study Quality
45 (25424870) 4
18 (26176603) 4
46 (24417798) 2
Variant 8: Head trauma with suspected intracranial arterial injury due to clinical risk factors or positive findings on prior imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTA head and neck with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 17
References Study Quality
60 (16688051) 3
56 (20154559) 4
45 (25424870) 4
57 (30097750) 4
Arteriography cervicocerebral May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 1 2 6 6 2 2 0
References Study Quality
60 (16688051) 3
45 (25424870) 4
MRA head and neck with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 5 1 1 2 8 1 1 0 0
References Study Quality
45 (25424870) 4
57 (30097750) 4
MRA head and neck without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 3 2 6 5 0 1 1
References Study Quality
45 (25424870) 4
57 (30097750) 4
MRA head and neck without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 0 2 1 8 5 1 1 1
References Study Quality
45 (25424870) 4
57 (30097750) 4
CT head without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 2 0 1 1 11 1 0 0 3
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 18 0 0 0 0 0 0 0 1
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 2 0 0 0 0 1 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 1 3 1 0 1 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 5 4 3 3 4 0 0 0 0
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 0 0 1 0 0 1 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 2 1 2 1 1 0 1 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 3 1 2 1 0 0 1 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 0 0 0 0 0 0 0
Variant 9: Head trauma with suspected intracranial venous injury due to clinical risk factors or positive findings on prior imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CTV head with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 9 9 0 0 0 0 0 0 0 2 16
References Study Quality
58 (25086806) 4
61 (28448419) 2
MRI head without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 4 1 1 1 10 1 1 0 0
MRV head with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 4 0 1 2 6 4 2 0 0
References Study Quality
58 (25086806) 4
MRV head without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 7 4 5 1 0
References Study Quality
58 (25086806) 4
MRV head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 0 0 1 1 5 4 7 1 0
References Study Quality
58 (25086806) 4
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 1 0 1 3 6 6 1 0 1
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 2 4 0 0 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 2 1 0 1 0 1 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 4 1 1 1 0 0 0
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 1 0 0 1 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 1 2 1 2 0 0 0 1
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 1 1 4 0 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
Variant 10: Head trauma with suspected cerebrospinal fluid (CSF) leak. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT maxillofacial without IV contrast Usually appropriate Limited ☢☢ 0.1-1mSv 9 9 0 0 0 0 0 1 1 1 16
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 0 0 0 2 4 13
References Study Quality
58 (25086806) 4
66 (12087336) 3
64 (29910174) 4
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 8 8 0 0 0 1 2 1 4 2 8
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
MRI head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 1 2 11 3 2 0 0
References Study Quality
66 (12087336) 3
64 (29910174) 4
CT head cisternography May be appropriate Limited ☢☢☢ 1-10 mSv 5 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
58 (25086806) 4
64 (29910174) 4
CT head cisternography May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 0 2 10 4 2 1 0
References Study Quality
58 (25086806) 4
64 (29910174) 4
DTPA cisternography May be appropriate Limited ☢☢☢ 1-10 mSv 4 4 0 1 1 8 7 2 0 0 0
References Study Quality
65 (10319986) 3
66 (12087336) 3
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 0 0 0 1
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 0 1 0 0 0 0 0 0
MRI head with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
66 (12087336) 3
64 (29910174) 4
MRI head with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 11 1 1 1 3 1 0 0 0
References Study Quality
66 (12087336) 3
64 (29910174) 4
MRI head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 2 6 0 1 0 0 0 0
References Study Quality
66 (12087336) 3
64 (29910174) 4
MRI head without IV contrast with DTI Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 0 0 1 0 0 0 1 0
CT maxillofacial with IV contrast Usually not appropriate Limited ☢☢ 0.1-1mSv 1 1 10 1 3 1 2 0 0 0 1
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 1 1 0 0 0 0 0
References Study Quality
58 (25086806) 4
66 (12087336) 3
64 (29910174) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 1 0 1 0 0 0 0
References Study Quality
58 (25086806) 4
66 (12087336) 3
64 (29910174) 4
CT maxillofacial without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 18 1 0 0 0 0 0 0 0
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
CT temporal bone with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 1 2 0 1 1 0 0 1
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
CT temporal bone without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 12 1 2 2 0 0 0 0 1
References Study Quality
58 (25086806) 4
65 (10319986) 3
66 (12087336) 3
64 (29910174) 4
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.