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Appropriateness Criteria

Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI complete spine without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 1 11 2 2
References Study Quality
36 (24107860) 3
25 (18768717) 2
35 (32402615) 2
34 (19949036) 2
52 (32554417) 2
MRI complete spine without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 1 2 1 3 3 5
References Study Quality
36 (24107860) 3
25 (18768717) 2
35 (32402615) 2
34 (19949036) 2
MRI head without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 11
References Study Quality
25 (18768717) 2
16 (30776059) 2
26 (34579563) 2
MRI head without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 1 0 0 3 4 5 3 0
References Study Quality
25 (18768717) 2
26 (34579563) 2
16 (30776059) 2
CT myelography complete spine May be appropriate Strong ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 1 1 7 4 2 0 0 0
References Study Quality
36 (24107860) 3
35 (32402615) 2
34 (19949036) 2
Radiographic myelography digital subtraction complete spine Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 2 8 3 2 2 0 0 0 1 0
References Study Quality
25 (18768717) 2
44 (35332017) 4
43 (37128777) 4
42 (31518974) 2
41 (31857327) 4
40 (33122215) 4
54 (26849709) 4
53 (33484155) 2
MR myelography complete spine Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 7 1 0 0 0 0 0 0
References Study Quality
48 (22173753) 4
49 (24852289) 2
47 (34292360) 4
50 (32354709) 4
51 (32720867) 4
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 3 0 1 0 1 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 3 2 0 0 1 0 0
CT head cisternography Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 13 3 0 0 0 0 0 0 0
References Study Quality
22 (22264184) 2
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 13 2 0 1 0 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 0 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 11 2 2 1 0 0 0 0 0
DTPA cisternography Usually not appropriate Limited ☢☢☢ 1-10 mSv 2 2 8 1 3 2 1 1 0 0 0
References Study Quality
46 (22990687) 2
45 (26823556) 4
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 1 0 0 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT myelography dynamic complete spine Usually not appropriate Strong ☢☢☢☢☢ 30-100 mSv 2 2 7 4 4 0 1 0 0 0 0
References Study Quality
24 (35261281) 4
39 (35614322) 2
38 (30226459) 2
37 (33602750) 2
44 (35332017) 4
43 (37128777) 4
42 (31518974) 2
41 (31857327) 4
40 (33122215) 4
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiographic myelography digital subtraction complete spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 1 0 0 0 0 0 0 0
MR myelography complete spine Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 1 1 0 0 0 0
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
MRI complete spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 1 0 0 0 0
MRI complete spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 1 0 0 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 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 13 0 2 0 0 0 1 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 2 0 1 0 0 0 0
CT head cisternography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 0 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] 1 1 15 1 0 0 0 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 2 0 1 1 1 0 0
DTPA cisternography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 14 0 1 1 0 0 0 0 0
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 0 1 1 1 0 0 0 0
CT myelography dynamic complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv 1 1 15 0 0 0 1 0 0 0 0
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiographic myelography digital subtraction complete spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 15 1 0 0 0 0 0 0 0
MR myelography complete spine Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 0 0 0 1 0 0
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
MRI complete spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 0 0 0 2 0 0
MRI complete spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 2 0 0 1 1 0 0
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 15 1 0 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 11 0 1 2 1 0 1 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 0 1 2 1 0 1 0 0
CT head cisternography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 0 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] 1 1 15 1 0 0 0 0 0 0 0
CT head without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 10 0 1 1 2 1 0 1 0
DTPA cisternography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 13 0 2 0 1 0 0 0 0
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 0 0 0 0 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 0 1 0 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 0 2 0 1 0 1 0 0
CT myelography dynamic complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv 1 1 15 0 0 0 1 0 0 0 0
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI complete spine without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 0 8 4 3
References Study Quality
36 (24107860) 3
28 (20651205) 4
25 (18768717) 2
35 (32402615) 2
34 (19949036) 2
MRI complete spine without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 3 8 5
References Study Quality
36 (24107860) 3
25 (18768717) 2
35 (32402615) 2
34 (19949036) 2
CT myelography complete spine May be appropriate Strong ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 0 3 12 0 1 0 0
References Study Quality
34 (19949036) 2
35 (32402615) 2
Radiographic myelography digital subtraction complete spine Usually not appropriate Strong ☢☢☢☢ 10-30 mSv 2 2 6 3 6 0 0 0 1 0 0
References Study Quality
24 (35261281) 4
44 (35332017) 4
43 (37128777) 4
42 (31518974) 2
41 (31857327) 4
40 (33122215) 4
54 (26849709) 4
53 (33484155) 2
MR myelography complete spine Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 6 2 7 0 0 0 0 1 0
References Study Quality
48 (22173753) 4
49 (24852289) 2
47 (34292360) 4
50 (32354709) 4
51 (32720867) 4
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 3 1 0 1 0 0 0 0
DTPA cisternography Usually not appropriate Limited ☢☢☢ 1-10 mSv 3 3 6 2 1 4 2 1 0 0 0
References Study Quality
46 (22990687) 2
45 (26823556) 4
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 0 0 1 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 0 0 1 1 0 0 0 0
CT myelography dynamic complete spine Usually not appropriate Strong ☢☢☢☢☢ 30-100 mSv 2 2 6 4 6 0 0 0 0 0 0
References Study Quality
24 (35261281) 4
39 (35614322) 2
38 (30226459) 2
37 (33602750) 2
44 (35332017) 4
43 (37128777) 4
42 (31518974) 2
41 (31857327) 4
40 (33122215) 4
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiographic myelography digital subtraction complete spine Usually appropriate Strong ☢☢☢☢ 10-30 mSv 8 8 0 1 0 1 1 0 3 4 6
References Study Quality
24 (35261281) 4
54 (26849709) 4
53 (33484155) 2
44 (35332017) 4
43 (37128777) 4
42 (31518974) 2
41 (31857327) 4
40 (33122215) 4
CT myelography dynamic complete spine Usually appropriate Strong ☢☢☢☢☢ 30-100 mSv 8 8 0 0 0 0 0 1 2 6 7
References Study Quality
24 (35261281) 4
39 (35614322) 2
38 (30226459) 2
37 (33602750) 2
44 (35332017) 4
43 (37128777) 4
42 (31518974) 2
41 (31857327) 4
40 (33122215) 4
MR myelography complete spine May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 0 12 4 0 0 0
References Study Quality
48 (22173753) 4
47 (34292360) 4
49 (24852289) 2
50 (32354709) 4
51 (32720867) 4
DTPA cisternography May be appropriate Limited ☢☢☢ 1-10 mSv 5 5 0 0 0 1 14 1 0 0 0
References Study Quality
46 (22990687) 2
45 (26823556) 4
CT head cisternography Usually not appropriate Limited ☢☢☢ 1-10 mSv 1 1 14 1 0 0 1 0 0 0 0
References Study Quality
22 (22264184) 2
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiographic myelography digital subtraction complete spine Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 14 1 0 1 0 0 0 0 0
MR myelography complete spine Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 1 0 0 0 0 0
MRI complete spine with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 1 0 0 0 0 0 0
MRI complete spine without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 0 1 0 1 0 1 0 0
MRI complete spine without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 0 1 2 1 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 0 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 10 0 1 3 0 0 1 0 1
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 12 1 1 1 0 0 0 1 0
CT head cisternography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 2 0 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] 1 1 14 1 0 0 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 0 0 0 0 1 0 0
DTPA cisternography Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 15 1 0 0 0 0 0 0 0
CT complete spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
CT complete spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 1 0 0 0 0 0
CT complete spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 0 0 0 0 0 0 0
CT myelography complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 1 0 0 0 0 1 0 0
CT myelography dynamic complete spine Usually not appropriate Expert Consensus ☢☢☢☢☢ 30-100 mSv 1 1 14 1 0 0 0 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.