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Appropriateness Criteria

Variant 1: Infant. Clinical signs or symptoms of infantile hemangioma. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 1 0 0 3 3 11
References Study Quality
14 (31421839) 3
21 (10715041) 4
US duplex Doppler area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 1 0 0 2 2 2 12
References Study Quality
14 (31421839) 3
21 (10715041) 4
MRA and MRV area of interest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 2 0 0 5 8 2 0 0 1
References Study Quality
15 (21594550) 4
MRI area of interest without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 0 2 6 7 0 0 1
References Study Quality
17 (21607598) 4
CT area of interest with IV contrast May be appropriate Limited Varies Varies 4 4 6 1 1 6 3 1 1 0 0
References Study Quality
20 (15671395) 4
US area of interest with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 7 3 0 1 0 0 0 0
Arteriography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 17 1 0 1 0 0 0 0 0
Radiography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 11 4 2 2 0 0 0 0 0
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 2 6 2 0 1 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 1 1 14 2 3 0 0 0 0 0 0
References Study Quality
20 (15671395) 4
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 16 3 0 0 0 0 0 0 0
CTA and CTV area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 15 2 2 0 0 0 0 0 0
Variant 2: Infant. Multiple cutaneous infantile hemangiomas, screening for infantile hepatic hemangiomas. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US abdomen Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 1 1 5 4 7
References Study Quality
13 (28089471) 4
23 (33285272) 2
26 (29957348) 2
US duplex Doppler abdomen Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 1 0 2 4 10
References Study Quality
26 (29957348) 2
25 (30244993) 4
US abdomen with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 2 0 2 6 2 3 2 0
References Study Quality
28 (29019750) 4
27 (31967502) 4
26 (29957348) 2
Radiography abdomen Usually not appropriate Expert Consensus ☢☢ 0.1-1mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 16 2 1 0 0 0 0 0 0
Arteriography abdomen Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 17 1 0 1 0 0 0 0 0
CTA and CTV abdomen with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢☢ 10-30 mSv [ped] 1 1 16 1 1 0 1 0 0 0 0
MRA and MRV abdomen without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 3 3 2 0 1 0 0 0
MRI abdomen without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 8 8 2 0 0 0 0 0 0
References Study Quality
25 (30244993) 4
MRI abdomen without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 8 3 2 1 3 1 1 0 0
CT abdomen with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 14 3 1 0 0 0 0 0 0
CT abdomen without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 17 1 1 0 0 0 0 0 0
CT abdomen without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 1 1 16 3 0 0 0 0 0 0 0
Variant 3: Child. Clinical signs or symptoms of vascular anomaly (tumor or malformation) not suggesting infantile hemangioma. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 0 0 2 10 3 3
References Study Quality
21 (10715041) 4
37 (29219827) 3
36 (24147487) 4
US duplex Doppler area of interest Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 1 0 0 1 5 3 9
References Study Quality
36 (24147487) 4
MRA and MRV area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 0 1 11 4
References Study Quality
32 (32548214) 4
31 (21918047) 4
30 (26905867) 2
29 (11959728) 1
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 1 1 5 8 3
References Study Quality
31 (21918047) 4
US area of interest with IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 0 1 9 4 2 0 0
References Study Quality
28 (29019750) 4
27 (31967502) 4
26 (29957348) 2
MRA area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 1 0 1 10 3 1 1 0
References Study Quality
34 (15306760) 4
33 (33893543) 4
MRI area of interest without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 1 3 11 1 0 0 1
References Study Quality
31 (21918047) 4
Arteriography area of interest Usually not appropriate Expert Consensus Varies Varies 1 1 16 1 0 0 1 1 0 0 0
Radiography area of interest Usually not appropriate Limited Varies Varies 3 3 9 0 2 2 4 2 0 0 0
References Study Quality
35 (30300008) 3
CT area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 10 3 4 1 1 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 15 2 1 1 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 16 2 1 0 0 0 0 0 0
CTA and CTV area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 9 3 3 2 2 0 0 0 0
Variant 4: Child. Ultrasound features raise suspicion for vascular malformation. Next imaging study.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRA and MRV area of interest without and with IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 1 3 6 7
References Study Quality
47 (22840741) 3
46 (31425807) 3
32 (32548214) 4
30 (26905867) 2
29 (11959728) 1
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 2 0 2 2 0 6 7
References Study Quality
31 (21918047) 4
CT area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 1 0 0 3 13 0 0 1 0
References Study Quality
41 (27517361) 4
40 (32145596) 4
39 (25625123) 4
CTA and CTV area of interest with IV contrast May be appropriate Limited Varies Varies 5 5 1 1 0 2 13 0 1 0 0
References Study Quality
45 (31559161) 4
42 (30057879) 4
41 (27517361) 4
40 (32145596) 4
39 (25625123) 4
US area of interest with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 6 5 7 0 0 0 0 0 0
References Study Quality
48 (25110772) 4
Arteriography area of interest Usually not appropriate Limited Varies Varies 2 2 7 4 3 1 3 0 0 0 0
References Study Quality
38 (15466793) 2
Radiography area of interest Usually not appropriate Limited Varies Varies 2 2 9 4 2 3 1 0 0 0 0
References Study Quality
35 (30300008) 3
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 3 7 7 1 0 0 0 0 0
CT area of interest without and with IV contrast Usually not appropriate Limited Varies Varies 2 2 8 7 3 0 0 0 0 0 0
References Study Quality
43 (26560716) 2
42 (30057879) 4
41 (27517361) 4
40 (32145596) 4
39 (25625123) 4
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 2 4 0 0 0 0 0 0
Variant 5: Child. Established diagnosis of vascular malformation presenting with new or persistent signs or symptoms. 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 area of interest Usually appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 1 0 4 10 2
MRA and MRV area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 2 0 0 0 2 4 2 6 3
References Study Quality
29 (11959728) 1
47 (22840741) 3
MRI area of interest without and with IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 0 0 10 7 1
References Study Quality
31 (21918047) 4
US area of interest May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 6 6 0 0 1 0 7 6 1 2 1
US area of interest with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 1 1 1 4 7 3 1 0 0
References Study Quality
50 (26444594) 3
Arteriography area of interest Usually not appropriate Limited Varies Varies 2 2 7 7 2 2 0 0 0 0 0
References Study Quality
49 (23101921) 1
Radiography area of interest Usually not appropriate Limited Varies Varies 3 3 7 1 3 2 6 0 0 0 0
References Study Quality
35 (30300008) 3
MRI area of interest without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 4 3 5 4 2 1 0 0 0
CT area of interest with IV contrast Usually not appropriate Limited Varies Varies 3 3 7 0 4 6 1 1 0 0 0
References Study Quality
39 (25625123) 4
CT area of interest without and with IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 13 1 5 0 0 0 0 0 0
CT area of interest without IV contrast Usually not appropriate Expert Consensus Varies Varies 1 1 14 2 2 0 0 1 0 0 0
CTA and CTV area of interest with IV contrast Usually not appropriate Expert Consensus Varies Varies 2 2 7 4 5 1 1 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.