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Appropriateness Criteria

Variant 1: Adult. Altered mental status. Suspected intracranial pathology or focal neurologic deficit. 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 4 4 10
References Study Quality
2 (19773662) 2
34 (18336626) 2
33 (22186148) 4
32 (22978732) 4
31 (19787177) 2
30 (24927985) 2
29 (25763568) 1
10 (17324689) 4
8 (24733711) 4
MRI head without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 2 10 4 1 0 0
References Study Quality
10 (17324689) 4
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 1 5 4 6 0 3
References Study Quality
38 (25260346) 4
37 (34973968) 2
36 (22633790) 2
35 (27220652) 2
34 (18336626) 2
29 (25763568) 1
33 (22186148) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 16 1 0 0 0 0 0 1 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 9 9 0 0 0 0 0 0 0
References Study Quality
28 (25173368) 4
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 3 1 0 1 0 0 1
Variant 2: Adult. Altered mental status with known history of intracranial pathology. 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 and with IV contrast Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 5 2 5 4 3
MRI head without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 3 4 6 2 2
References Study Quality
2 (19773662) 2
CT head without IV contrast Usually appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 1 0 1 1 1 7 4 3
CT head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 2 2 0 10 4 0 0 0 0
References Study Quality
30 (24927985) 2
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 4 5 0 0 0 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 2 8 2 4 1 1 0 0 0
Variant 3: Adult. Altered mental status. Suspected medical illness or toxic-metabolic cause. 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 May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 0 1 10 5 0 0 0
References Study Quality
40 (28298967) 4
CT head without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 0 2 9 3 1 2 0
References Study Quality
39 (27743625) 4
15 (22362650) 2
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 5 2 0 1 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 4 2 0 3 0 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 4 1 1 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 11 3 2 1 0 1 1 0 0
Variant 4: Adult. Altered mental status despite clinical management of known medical illness or toxic-metabolic cause. 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] 7 7 0 0 0 1 1 4 5 3 5
References Study Quality
39 (27743625) 4
30 (24927985) 2
15 (22362650) 2
32 (22978732) 4
2 (19773662) 2
MRI head without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 0 0 2 9 4 1 0 2
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 0 0 0 3 7 6 0 3
References Study Quality
35 (27220652) 2
29 (25763568) 1
38 (25260346) 4
36 (22633790) 2
41 (19017925) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 5 1 0 4 0 0 0 0
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 5 3 4 5 2 0 0 0 0
References Study Quality
29 (25763568) 1
28 (25173368) 4
33 (22186148) 4
32 (22978732) 4
2 (19773662) 2
31 (19787177) 2
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 4 5 0 0 0 1 0 0
Variant 5: Adult. New onset psychosis. 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 and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 1 2 11 3 0 0 0
References Study Quality
44 (29103181) 2
46 (25174841) 4
MRI head without IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 5 5 0 1 0 2 7 8 0 0 0
References Study Quality
45 (22959259) 2
49 (15000267) 4
48 (28335913) 4
46 (25174841) 4
50 (22416264) 2
42 (19660172) 4
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 1 1 10 5 0 0 0
References Study Quality
45 (22959259) 2
49 (15000267) 4
48 (28335913) 4
46 (25174841) 4
47 (20958941) 4
42 (19660172) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 9 6 1 1 0 1 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 5 0 1 2 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 11 4 1 0 1 1 0 1 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.