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Appropriateness Criteria

Variant 1: Infant. Suspected hydrocephalus. Abnormal prenatal imaging or signs or symptoms of elevated intracranial pressure. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US head Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 0 4 2 5
References Study Quality
29 (33399982) 4
12 (31310185) 2
11 (30366745) 4
MRI head without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 3 8
References Study Quality
14 (29850941) 4
13 (25559932) 4
25 (25469096) 0
MRI head without IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 1 1 6 2 3
References Study Quality
14 (29850941) 4
13 (25559932) 4
19 (24559278) 4
25 (25469096) 0
18 (23111234) 4
MRI head without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 10 0 1 0 0
References Study Quality
14 (29850941) 4
13 (25559932) 4
25 (25469096) 0
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 1 1 3 2 3 3 0
References Study Quality
21 (25082822) 2
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 3 0 0 0 0 0 0
References Study Quality
14 (29850941) 4
13 (25559932) 4
25 (25469096) 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 2 2 1 0 1 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 2 1 1 1 0 0 0 1
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 5 2 1 2 3 0 0 0 0
References Study Quality
21 (25082822) 2
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 1 0 0 0 0 0
References Study Quality
21 (25082822) 2
Variant 2: Infant. Known hydrocephalus. Follow-up 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 Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 1 3 5 4
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRI head without IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 2 10
References Study Quality
14 (29850941) 4
26 (25859808) 4
19 (24559278) 4
25 (25469096) 0
13 (25559932) 4
18 (23111234) 4
15 (23026416) 4
Radiography head neck chest abdomen May be appropriate Expert Consensus ☢☢ 0.03-0.3 mSv [ped] 5 5 0 0 0 0 7 0 5 0 0
References Study Quality
45 (25259566) 3
US head May be appropriate Limited O 0 mSv O 0 mSv [ped] 6 6 1 0 0 0 3 3 2 1 3
References Study Quality
29 (33399982) 4
12 (31310185) 2
11 (30366745) 4
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 0 0 2 5 3 3 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 1 2 0 0 0 0 0 0
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 1 5 1 3 0 0 0 0
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 4 0 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 0 4 0 0 0 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 2 1 1 0 1 0 0 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 1 1 0 1 0 0 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
Variant 3: Infant. Macrocephaly. No signs or symptoms of elevated intracranial pressure. Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
US head Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 1 1 0 1 1 3 6
References Study Quality
29 (33399982) 4
12 (31310185) 2
11 (30366745) 4
MRI head without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 0 3 4 4
References Study Quality
28 (30704866) 4
14 (29850941) 4
25 (25469096) 0
13 (25559932) 4
33 (27989412) 4
MRI head without IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 1 1 2 8
References Study Quality
28 (30704866) 4
14 (29850941) 4
19 (24559278) 4
25 (25469096) 0
13 (25559932) 4
33 (27989412) 4
18 (23111234) 4
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 1 0 0 3 4 2 2 0
References Study Quality
28 (30704866) 4
33 (27989412) 4
21 (25082822) 2
Radiography head neck chest abdomen Usually not appropriate Expert Consensus ☢☢ 0.03-0.3 mSv [ped] 1 1 11 1 0 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 7 1 3 1 1 0 0 0 0
References Study Quality
28 (30704866) 4
14 (29850941) 4
25 (25469096) 0
13 (25559932) 4
33 (27989412) 4
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 2 4 0 0 1 0 0 0
References Study Quality
28 (30704866) 4
14 (29850941) 4
25 (25469096) 0
13 (25559932) 4
33 (27989412) 4
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 1 0 0 1 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 1 0 0 0 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 3 1 0 0 0 0 0 0
References Study Quality
28 (30704866) 4
33 (27989412) 4
21 (25082822) 2
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 0 0 0 0 0 0
References Study Quality
28 (30704866) 4
33 (27989412) 4
21 (25082822) 2
Variant 4: Child greater than 1 year of age. Suspected hydrocephalus. Signs or symptoms of elevated intracranial pressure. 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 Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 1 0 1 4 7
References Study Quality
14 (29850941) 4
13 (25559932) 4
25 (25469096) 0
MRI head without IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 0 1 3 5 3
References Study Quality
14 (29850941) 4
13 (25559932) 4
19 (24559278) 4
25 (25469096) 0
18 (23111234) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 0 1 1 4 6 1
References Study Quality
21 (25082822) 2
MRI head without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 0 0 1 6 2 2 1 0
References Study Quality
14 (29850941) 4
13 (25559932) 4
25 (25469096) 0
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 2 0 0 0 0 0 0
References Study Quality
12 (31310185) 2
11 (30366745) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 3 0 0 0 0 0 0
References Study Quality
14 (29850941) 4
13 (25559932) 4
25 (25469096) 0
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 0 6 1 2 1 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 2 4 6 0 0 0 0 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 5 1 3 2 1 0 0 0 0
References Study Quality
21 (25082822) 2
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 5 2 3 1 1 1 0 0 0
References Study Quality
21 (25082822) 2
Variant 5: Child greater than 1 year of age. Known hydrocephalus. No signs or symptoms of shunt malfunction. Follow-up 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 Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 0 2 1 5 4 1
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRI head without IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 0 3 10
References Study Quality
14 (29850941) 4
26 (25859808) 4
19 (24559278) 4
25 (25469096) 0
13 (25559932) 4
18 (23111234) 4
15 (23026416) 4
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 1 0 0 0 2 5 2 2 1
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
Radiography head neck chest abdomen Usually not appropriate Expert Consensus ☢☢ 0.03-0.3 mSv [ped] 3 3 4 1 3 1 3 0 0 1 0
References Study Quality
45 (25259566) 3
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 2 1 0 0 0 0 0 0
References Study Quality
12 (31310185) 2
11 (30366745) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 3 1 0 1 0 0 0
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRI head without and with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 3 0 0 0 0 0 0
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 2 1 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 2 0 0 0 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 1 2 0 0 1 0 0 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 0 0 0 0 0 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
Variant 6: Child. Known hydrocephalus with cerebral spinal fluid diversion. Signs or symptoms of shunt malfunction. Follow-up imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiography head neck chest abdomen Usually appropriate Limited ☢☢ 0.03-0.3 mSv [ped] 8 8 1 0 0 0 0 2 1 4 5
References Study Quality
45 (25259566) 3
MRI head without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 0 1 6 3 2
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRI head without IV contrast abbreviated Usually appropriate Limited O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 1 3 9
References Study Quality
14 (29850941) 4
26 (25859808) 4
19 (24559278) 4
25 (25469096) 0
13 (25559932) 4
18 (23111234) 4
15 (23026416) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 7 7 0 0 0 0 0 2 6 3 2
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
US abdomen May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 0 1 1 5 2 2 1 1
MRI head without and with IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 1 0 2 2 5 1 1 0 0
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
Nuclear medicine ventriculography May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 3 1 3 3 1 0 1 0
References Study Quality
44 (33084363) 4
US head Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 9 2 1 0 1 0 0 0 0
References Study Quality
12 (31310185) 2
11 (30366745) 4
MRI head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 7 1 3 1 0 0 0 1 0
References Study Quality
14 (29850941) 4
26 (25859808) 4
25 (25469096) 0
13 (25559932) 4
15 (23026416) 4
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 2 2 1 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 8 1 3 0 0 0 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 3 2 1 0 1 0 0 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 0 0 1 0 0 0 0
References Study Quality
43 (27989409) 4
42 (26474707) 4
21 (25082822) 2
22 (25779098) 3
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.