ACR logo

Appropriateness Criteria

Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. 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 Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 0 1 0 1 0 0 1 0
References Study Quality
2 (22273264) 4
33 (20495486) 4
9 (17056862) 3
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 1
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 0 0 0 0 0 1 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 17 1 0 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 16 1 1 0 0 0 0 1 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 1 1 1 3 0 0 0 0
CT head with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 18 0 0 0 0 0 0 1 0
References Study Quality
15 (27488722) 3
31 (26584662) 3
12 (24927811) 4
16 (24431418) 3
5 (19758692) 2
14 (24635987) 1
CT head without and with IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 1
References Study Quality
15 (27488722) 3
31 (26584662) 3
12 (24927811) 4
16 (24431418) 3
5 (19758692) 2
14 (24635987) 1
CT head without IV contrast Usually not appropriate Strong ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 2 2 0 2 0 0 0 1
References Study Quality
15 (27488722) 3
31 (26584662) 3
12 (24927811) 4
16 (24431418) 3
5 (19758692) 2
14 (24635987) 1
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 1 0
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. 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 May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 1 1 0 1 6 9 1 1 1
References Study Quality
5 (19758692) 2
Radiography skull Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 19 2 0 0 0 0 0 0 0
References Study Quality
2 (22273264) 4
33 (20495486) 4
9 (17056862) 3
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 18 0 0 0 0 0 0 0 1
MRA 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 1
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 0 2 1 0 0 0 1
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 0 1 1 2 1 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 10 7 2 2 0 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 16 2 0 0 0 0 0 1 0
References Study Quality
5 (19758692) 2
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 2 0 0 0 0 0 1 0
References Study Quality
5 (19758692) 2
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 2 1 1 0 0 0 1
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. 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 Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 0 0 0 0 0 0 0 2 19
References Study Quality
5 (19758692) 2
Radiography skull Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 18 3 0 0 0 0 0 0 0
References Study Quality
2 (22273264) 4
33 (20495486) 4
9 (17056862) 3
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 0 0 0 0 0 0 0
MRA head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 19 2 0 0 0 0 0 0 0
References Study Quality
34 (22172317) 4
35 (21908994) 4
19 (21318614) 4
MRA head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 15 3 2 1 0 0 0 0 0
References Study Quality
34 (22172317) 4
35 (21908994) 4
19 (21318614) 4
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 19 2 0 0 0 0 0 0 0
MRI head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 10 2 4 3 2 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 19 1 1 0 0 0 0 0 0
References Study Quality
5 (19758692) 2
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 1 0 0 0 0 0 0 0
References Study Quality
5 (19758692) 2
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 3 1 2 0 0 0 0 0
References Study Quality
34 (22172317) 4
35 (21908994) 4
19 (21318614) 4
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. 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 Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 9 9 1 0 0 0 0 0 0 0 18
References Study Quality
36 (18022444) 4
Radiography skull Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 19 0 0 1 1 0 0 0 0
References Study Quality
2 (22273264) 4
33 (20495486) 4
9 (17056862) 3
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 3 0 0 0 0 0 1
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 18 0 3 0 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 14 1 5 1 0 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 1 1 18 1 1 1 0 0 0 0 0
References Study Quality
25 (19852541) 2
39 (17437903) 2
MRI head without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 7 3 6 3 1 1 0 0 0
References Study Quality
25 (19852541) 2
39 (17437903) 2
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 15 1 2 0 0 1 0 0 0
References Study Quality
36 (18022444) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 1 1 0 1 0 1 0 0
References Study Quality
36 (18022444) 4
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 2 3 2 0 0 0 0 0
References Study Quality
37 (19760434) 4
19 (21318614) 4
38 (28916852) 4
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
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] 8 8 1 0 0 0 0 0 2 9 9
References Study Quality
28 (26381555) 2
31 (26584662) 3
29 (25700122) 2
30 (27072355) 2
38 (28916852) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 1 0 0 0 1 3 7 9
References Study Quality
43 (24064865) 3
44 (29784284) 3
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 0 1 0 0 1
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 16 0 1 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] 3 3 9 0 2 1 5 1 1 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 6 3 2 6 4 0 0 0 0
MRI head without and with IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 2 2 9 2 2 3 3 0 1 0 1
References Study Quality
28 (26381555) 2
31 (26584662) 3
29 (25700122) 2
30 (27072355) 2
38 (28916852) 4
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 12 1 1 1 2 0 2 0 0
References Study Quality
43 (24064865) 3
44 (29784284) 3
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 19 0 1 0 1 0 0 0 0
References Study Quality
43 (24064865) 3
44 (29784284) 3
CTA head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 7 1 3 0 6 1 1 0 0
References Study Quality
37 (19760434) 4
19 (21318614) 4
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
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 Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 4 16
References Study Quality
47 (28095029) 3
49 (27482782) 4
45 (28490224) 4
41 (29157852) 4
46 (26419243) 4
MRA head without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 6 1 0 8 3 3 0 0 0
MRI head without and with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 10 1 5 2 0 2 0 0 1
References Study Quality
47 (28095029) 3
49 (27482782) 4
45 (28490224) 4
41 (29157852) 4
46 (26419243) 4
MRI head without IV contrast with DTI May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 8 1 8 1 0 1 0 1 1
CT head without IV contrast May be appropriate (Disagreement) Expert Opinion ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 7 2 7 2 0 1 0 0 2
References Study Quality
47 (28095029) 3
46 (26419243) 4
Radiography skull Usually not appropriate Limited ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 17 0 0 0 1 0 0 0 1
References Study Quality
48 (-3149364) 4
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 3 1 0 0 0 0 1 0
MR spectroscopy head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 2 0 3 2 2 0 0 0
References Study Quality
50 (24735414) 3
MRA head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 1 3 3 1 0 1 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 10 3 1 0 4 1 0 0 0
References Study Quality
51 (29560308) 4
52 (28085565) 4
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 14 1 1 1 0 0 1 1 0
References Study Quality
47 (28095029) 3
46 (26419243) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 20 0 0 1 0 0 0 0 0
References Study Quality
47 (28095029) 3
46 (26419243) 4
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 9 2 2 2 3 1 0 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 3 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.