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Appropriateness Criteria

Variant 1: Adult. Suspected or known hypofunctioning pituitary gland (hypopituitarism, growth hormone deficiency, growth deceleration, panhypopituitarism, hypogonadotropic hypogonadism). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sella without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 14
References Study Quality
2 (27890190) 4
1 (27003878) 4
25 (26614829) 4
24 (24364195) 3
19 (22875743) 4
27 (23040741) 4
23 (22749386) 4
26 (21470998) 4
44 (17964033) 4
35 (17524347) 4
61 (17467517) 4
31 (17698579) 4
32 (17873755) 4
34 (17157037) 4
37 (17576206) 4
38 (20020580) 3
39 (19963090) 3
41 (17578763) 3
42 (17159354) 4
47 (17594050) 4
48 (20197674) 3
52 (18046535) 4
53 (19320653) 4
54 (18174733) 4
58 (18625361) 4
59 (17126479) 4
55 (19809320) 4
57 (17954416) 4
30 (1593348) 4
33 (11022195) 4
40 (8222293) 3
45 (1424165) 2
49 (15379423) 4
50 (2064861) 3
56 (2112091) 4
64 (2677826) 4
65 (7945110) 4
28 (1564527) 4
29 (20500966) 4
36 (18317442) 4
43 (18226737) 4
46 (17964354) 4
60 (18209870) 4
51 (2336284) 4
63 (25658782) 2
62 (10796926) 2
MRI sella without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 1 2 9 1 0
References Study Quality
2 (27890190) 4
1 (27003878) 4
25 (26614829) 4
24 (24364195) 3
19 (22875743) 4
27 (23040741) 4
23 (22749386) 4
26 (21470998) 4
44 (17964033) 4
35 (17524347) 4
61 (17467517) 4
31 (17698579) 4
32 (17873755) 4
34 (17157037) 4
37 (17576206) 4
38 (20020580) 3
39 (19963090) 3
41 (17578763) 3
42 (17159354) 4
47 (17594050) 4
48 (20197674) 3
52 (18046535) 4
53 (19320653) 4
54 (18174733) 4
58 (18625361) 4
59 (17126479) 4
55 (19809320) 4
57 (17954416) 4
30 (1593348) 4
33 (11022195) 4
40 (8222293) 3
45 (1424165) 2
49 (15379423) 4
50 (2064861) 3
56 (2112091) 4
28 (1564527) 4
29 (20500966) 4
36 (18317442) 4
43 (18226737) 4
46 (17964354) 4
60 (18209870) 4
51 (2336284) 4
63 (25658782) 2
62 (10796926) 2
MRI sella with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 4 2 2 1 6 1 0 0 0
References Study Quality
2 (27890190) 4
1 (27003878) 4
25 (26614829) 4
24 (24364195) 3
19 (22875743) 4
27 (23040741) 4
23 (22749386) 4
26 (21470998) 4
44 (17964033) 4
35 (17524347) 4
61 (17467517) 4
31 (17698579) 4
32 (17873755) 4
34 (17157037) 4
37 (17576206) 4
38 (20020580) 3
39 (19963090) 3
41 (17578763) 3
42 (17159354) 4
47 (17594050) 4
48 (20197674) 3
52 (18046535) 4
53 (19320653) 4
54 (18174733) 4
58 (18625361) 4
59 (17126479) 4
55 (19809320) 4
57 (17954416) 4
30 (1593348) 4
33 (11022195) 4
40 (8222293) 3
45 (1424165) 2
49 (15379423) 4
50 (2064861) 3
56 (2112091) 4
64 (2677826) 4
65 (7945110) 4
28 (1564527) 4
29 (20500966) 4
36 (18317442) 4
43 (18226737) 4
46 (17964354) 4
60 (18209870) 4
51 (2336284) 4
63 (25658782) 2
62 (10796926) 2
CT sella with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 2 1 2 5 5 0 0 0
References Study Quality
18 (24594782) 3
12 (22084178) 4
Radiography sella Usually not appropriate Limited ☢ <0.1 mSv 1 1 13 2 0 0 0 0 0 0 0
References Study Quality
69 (8927393) 4
Venous sampling petrosal sinus Usually not appropriate Limited Varies Varies 1 1 14 1 0 0 0 0 0 0 0
References Study Quality
66 (21990499) 4
67 (8881446) 4
68 (22286783) 3
MRA head with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 4 4 1 0 1 0 0 0
References Study Quality
21 (11499817) 4
22 (1584359) 4
MRA head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 4 3 2 0 1 0 0 0
References Study Quality
21 (11499817) 4
22 (1584359) 4
MRA head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 1 6 4 0 1 0 0 0
References Study Quality
21 (11499817) 4
22 (1584359) 4
CT sella without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 2 1 3 1 0 0 0 0
References Study Quality
18 (24594782) 3
12 (22084178) 4
CT sella without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 2 3 3 5 1 1 0 0 0
References Study Quality
18 (24594782) 3
12 (22084178) 4
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 3 6 1 1 1 0 0 0
References Study Quality
20 (3683835) 3
Variant 2: Adult. Suspected or known hyperfunctioning pituitary adenoma (hyperthyroidism [high thyroid-stimulating hormone], Cushing syndrome [high adrenal corticotrophic hormone], hyperprolactinemia, acromegaly, or gigantism). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sella without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 1 14
References Study Quality
76 (26782836) 3
75 (24248770) 3
77 (22066905) 2
13 (21291344) 4
74 (20116954) 3
41 (17578763) 3
15 (2645603) 4
60 (18209870) 4
78 (16785841) 4
79 (11566239) 2
81 (28452619) 2
80 (11809542) 3
MRI sella without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 1 3 7 1 1
References Study Quality
76 (26782836) 3
77 (22066905) 2
41 (17578763) 3
15 (2645603) 4
60 (18209870) 4
78 (16785841) 4
79 (11566239) 2
81 (28452619) 2
80 (11809542) 3
MRI sella with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 4 2 1 2 6 1 0 0 0
References Study Quality
76 (26782836) 3
75 (24248770) 3
77 (22066905) 2
13 (21291344) 4
74 (20116954) 3
41 (17578763) 3
15 (2645603) 4
60 (18209870) 4
78 (16785841) 4
79 (11566239) 2
81 (28452619) 2
80 (11809542) 3
CT sella with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 2 2 0 4 7 0 0 0
References Study Quality
70 (2679524) 4
73 (8357624) 4
71 (6734060) 4
72 (8189257) 4
28 (1564527) 4
CT sella without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 3 3 1 5 3 0 0 0 0
Radiography sella Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 14 1 0 0 0 0 0 0 0
Venous sampling petrosal sinus Usually not appropriate Limited Varies Varies 2 2 7 2 2 2 1 1 0 0 0
References Study Quality
66 (21990499) 4
67 (8881446) 4
68 (22286783) 3
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 3 4 1 0 0 0 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 3 1 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 3 5 0 0 0 0 0 0
CT sella without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 3 1 0 2 1 0 0 0
References Study Quality
70 (2679524) 4
73 (8357624) 4
71 (6734060) 4
72 (8189257) 4
28 (1564527) 4
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 5 1 0 1 0 0 0
References Study Quality
20 (3683835) 3
Variant 3: Adult. Diabetes insipidus. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sella without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 15
References Study Quality
82 (22877954) 4
23 (22749386) 4
MRI sella without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 1 3 6 2 1
References Study Quality
82 (22877954) 4
23 (22749386) 4
MRI sella with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 4 2 2 1 6 1 0 0 0
References Study Quality
82 (22877954) 4
23 (22749386) 4
CT sella with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 2 1 0 4 7 1 0 0
CT sella without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 2 3 1 6 2 1 0 0 0
Radiography sella Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 0 0 0 0 0 0 0 0
Venous sampling petrosal sinus Usually not appropriate Expert Consensus Varies Varies 1 1 15 0 0 0 0 0 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 2 1 0 0 0 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 3 3 1 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 3 0 0 0 0 0 0
CT sella without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 1 2 0 3 1 0 0 0
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 4 1 1 1 0 0 0
References Study Quality
20 (3683835) 3
Variant 4: Adult. Pituitary apoplexy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sella without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 0 15
References Study Quality
83 (26414232) 4
85 (23585661) 3
84 (17898201) 2
MRI sella without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 2 2 5 4 1
References Study Quality
83 (26414232) 4
85 (23585661) 3
84 (17898201) 2
MRI sella with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 4 2 1 3 5 1 0 0 0
References Study Quality
83 (26414232) 4
85 (23585661) 3
CT sella with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 4 1 7 3 1 0 0 0
References Study Quality
16 (15927868) 4
CT sella without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 4 1 6 2 2 0 1 0
References Study Quality
16 (15927868) 4
Radiography sella Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 0 0 0 0 0 0 0 0
Venous sampling petrosal sinus Usually not appropriate Expert Consensus Varies Varies 1 1 15 0 0 0 0 0 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 3 2 1 0 0 0 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 1 1 1 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 4 1 2 0 0 0 0 0
CT sella without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 10 3 0 2 0 1 0 0 0
References Study Quality
16 (15927868) 4
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 5 1 1 0 0 0 0
References Study Quality
20 (3683835) 3
Variant 5: Adult. Surveillance postpituitary or sellar mass resection.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sella without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 0 14
References Study Quality
96 (28073906) 3
86 (21959621) 3
64 (2677826) 4
97 (29329735) 2
MRI sella without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 3 2 4 3 2
References Study Quality
96 (28073906) 3
97 (29329735) 2
MRI sella with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 4 2 2 2 4 1 1 0 0
References Study Quality
96 (28073906) 3
86 (21959621) 3
64 (2677826) 4
97 (29329735) 2
CT sella with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 2 1 5 3 3 1 0 0
References Study Quality
95 (21436342) 3
CT sella without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 1 3 4 7 1 0 0 0 0
References Study Quality
95 (21436342) 3
Radiography sella Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 0 0 0 0 0 0 0 0
Venous sampling petrosal sinus Usually not appropriate Expert Consensus Varies Varies 1 1 15 0 0 0 0 0 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 3 2 2 0 1 0 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 2 2 0 1 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 1 3 3 0 1 0 0 0
CT sella without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 1 2 2 1 2 0 0 0
References Study Quality
95 (21436342) 3
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 7 0 3 4 0 1 0 0 0
Variant 6: Child, males younger than 9 years of age; females younger than 8 years of age. Precocious puberty. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI sella without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 1 0 0 14
References Study Quality
105 (23150859) 4
107 (27148371) 4
112 (18509122) 4
113 (25878671) 3
MRI sella without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 4 2 6 2 1
References Study Quality
105 (23150859) 4
107 (27148371) 4
112 (18509122) 4
113 (25878671) 3
MRI sella with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 4 2 1 3 4 2 0 0 0
References Study Quality
105 (23150859) 4
107 (27148371) 4
112 (18509122) 4
113 (25878671) 3
Radiography sella Usually not appropriate Expert Consensus ☢ <0.1 mSv 1 1 15 0 0 0 0 0 0 0 0
Venous sampling petrosal sinus Usually not appropriate Expert Consensus Varies Varies 1 1 14 1 0 0 0 0 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 2 1 0 0 1 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 3 1 1 0 0 0 0 1
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 2 1 0 0 1 0 0
CT sella with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 2 8 3 3 0 0 0 0 0
References Study Quality
111 (3554937) 4
CT sella without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 1 3 2 1 0 0 0 0
References Study Quality
111 (3554937) 4
CT sella without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 3 5 1 3 1 2 0 0 0
References Study Quality
111 (3554937) 4
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 3 6 0 0 1 0 0 0
References Study Quality
20 (3683835) 3
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.