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Appropriateness Criteria

Variant 1: Pulsatile tinnitus, unilateral or bilateral; No retrotympanic lesion on otoscopy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRA head with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 1 1 0 0 4 1 7 3 1
References Study Quality
58 (25689158) 3
29 (21402614) 2
23 (17320776) 4
18 (19833802) 2
1 (16971601) 4
MRI head and internal auditory canal without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 2 4 9 3
References Study Quality
62 (15503045) 3
61 (17909826) 4
60 (18302544) M
CTA head and neck with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 8 8 0 0 0 0 2 2 3 3 8
References Study Quality
46 (30466644) 4
45 (22200123) 3
29 (21402614) 2
27 (23550183) 4
23 (17320776) 4
12 (18368578) 4
1 (16971601) 4
CTA head with IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 7 7 0 0 0 0 3 2 8 1 4
References Study Quality
46 (30466644) 4
29 (21402614) 2
27 (23550183) 4
12 (18368578) 4
MRA head without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 0 2 0 1 1 3 10 0 2
MRA head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 3 5 5 0 3
References Study Quality
59 (14684537) 2
58 (25689158) 3
29 (21402614) 2
23 (17320776) 4
1 (16971601) 4
MRI head and internal auditory canal without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 2 2 10 5 0 0 0
References Study Quality
62 (15503045) 3
61 (17909826) 4
60 (18302544) M
MRV head with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 13 5 1 0 0
References Study Quality
66 (33757666) 2
CT temporal bone without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv 5 5 5 6 2 1 2 2 1 0 0
References Study Quality
44 (22467283) 4
42 (32854043) 2
41 (30928582) 4
40 (16500440) 3
27 (23550183) 4
26 (24270723) 4
25 (24005164) 4
19 (24468899) 4
CTV head with IV contrast May be appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 0 6 5 5 1 1
References Study Quality
52 (33301285) 2
57 (28922875) 2
55 (32328770) 2
54 (29135862) 4
53 (31663989) 2
51 (29756346) 2
50 (31301193) 2
45 (22200123) 3
26 (24270723) 4
US duplex Doppler carotid artery Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 9 3 3 1 3 0 0 0 0
References Study Quality
69 (19453828) 3
68 (31928280) 2
US duplex Doppler transcranial Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 2 0 1 1 0 0 0
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 0 2 0 0 1 0 0 0
Arteriography cervicocerebral Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 6 2 2 2 0 0 0 0
References Study Quality
38 (23632978) 3
37 (15068515) 4
36 (2296650) 4
35 (29561378) 2
29 (21402614) 2
23 (17320776) 4
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 4 1 0 0 0 0 0 0
MRV head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 3 7 0 1 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 4 4 3 1 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 1 3 0 1 0 1 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 3 0 1 0 0 1 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 13 1 2 0 1 0 1 0 0
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 7 1 1 0 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 5 0 0 0 0 0 0 0
Variant 2: Pulsatile tinnitus, unilateral or bilateral; suspected retrotympanic lesion on otoscopy. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
CT temporal bone without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv 9 9 0 1 0 0 0 2 1 3 11
References Study Quality
1 (16971601) 4
36 (2296650) 4
39 (12856306) 4
CTA head and neck with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 1 0 2 4 11 1 0 0
References Study Quality
29 (21402614) 2
46 (30466644) 4
45 (22200123) 3
CTA head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 6 6 0 0 0 2 6 11 0 0 0
References Study Quality
29 (21402614) 2
46 (30466644) 4
45 (22200123) 3
CTV head with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 2 3 7 7 0 0 0
US duplex Doppler carotid artery Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 4 0 0 2 0 0 0 0
US duplex Doppler transcranial Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 2 0 0 0 0
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 1 0 0 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 2 0 1 1 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 8 1 3 2 2 1 1 0 0
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 2 1 1 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 8 1 5 2 1 0 1 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 3 1 0 0 0 0 0 0
MRI head and internal auditory canal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 3 5 2 3 0 0 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 2 0 3 1 0 1 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 3 0 1 0 0 0 0
MRV head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 2 0 1 0 1 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 3 0 1 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 1 0 3 0 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 1 0 2 1 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 2 1 1 0 0 0 0
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 2 2 8 6 5 0 0 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 11 2 1 0 2 1 0 1 0
Variant 3: Nonpulsatile tinnitus, unilateral; no hearing loss, and no neurologic deficit, and no trauma. 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 and internal auditory canal without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 1 0 0 0 3 6 7
References Study Quality
88 (20713245) 4
87 (31887752) 4
86 (28583226) 2
85 (31743294) 2
84 (30810586) 4
83 (20072012) 4
82 (12589857) 4
80 (19119337) 4
79 (21817934) 4
78 (32049565) 2
77 (19922702) 3
71 (32234748) 4
MRI head and internal auditory canal without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 2 0 0 3 7 6 1 0 0
References Study Quality
91 (24612912) 4
90 (1642833) 4
US duplex Doppler carotid artery Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 1 0 1 0 0
US duplex Doppler transcranial Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 1 1 0 0 0
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 1 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 0 1 1 0 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 1 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 14 1 1 0 1 0 0 1 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 1 1 0 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 2 0 2 0 1 1 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 0 1 1 0 1 0
MRV head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 2 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 2 1 0 2 1 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 13 1 1 1 1 1 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 2 1 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 1 1 1 1 0 0 0 0
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 2 1 1 0 0 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 18 1 0 0 0 0 0 0 0
CT temporal bone without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 15 2 0 1 0 1 0 0 0
References Study Quality
75 (29283099) 2
76 (1562895) 4
CTA head and neck with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 1 1 1 1 0 0 0
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 1 0 2 1 0 0 0
CTV head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 0 1 2 1 0 0 0
Variant 4: Nonpulsatile tinnitus, bilateral; no hearing loss, and no neurologic deficit, and no trauma. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US duplex Doppler carotid artery Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 1 0 1 0 0
US duplex Doppler transcranial Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 1 1 0 0 0
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 1 0 0 0
Arteriography cervicocerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 1 1 0 0 0 0
MRA head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 1 0 1 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 14 2 0 0 1 0 0 1 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 2 0 0 1 1 0 0 0
MRI head and internal auditory canal with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 0 1 0 1 1 0
MRI head and internal auditory canal without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
MRI head and internal auditory canal without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 2 0 0 0 0 0 0 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 0 1 2 0 0 0
MRV head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 2 0 2 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 1 2 1 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 0 1 2 1 0 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 1 1 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 1 1 1 0 1 0 0 0
CT temporal bone with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 1 1 0 1 1 0 0 0
CT temporal bone without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 0 0 1 0 1 0 1 0
CT temporal bone without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 16 3 0 0 0 0 0 0 0
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 0 1 0 1 0
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 1 0 1 1 0 0 0
CTV head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 0 2 1 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.