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Appropriateness Criteria

Variant 1: Child. Primary headache. 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 Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 15 0 0 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 11 1 0 2 0 1 0 0 0
MRI head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 1 1 8 3 1 1 1 0 0 1 0
References Study Quality
12 (24268890) 3
11 (22782255) 3
MRI head without IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 1 7 3 3 0 0 0 0
References Study Quality
12 (24268890) 3
11 (22782255) 3
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 13 2 0 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 11 1 2 1 0 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 9 3 3 0 0 0 0 0 0
References Study Quality
28 (23897870) 4
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 2 1 0 0 0 0 0
References Study Quality
28 (23897870) 4
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 6 2 3 1 1 1 1 0 0
References Study Quality
28 (23897870) 4
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 13 1 1 0 0 0 0 0 0
CTV head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 3 0 0 0 0 0 0 0
Variant 2: Child. Secondary headache. 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 Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 0 1 1 3 4 4 2
References Study Quality
17 (24529619) 3
34 (23966248) 4
33 (22766676) 3
38 (21439575) 3
37 (24485928) 3
39 (18765144) 4
30 (2022972) 4
31 (9051039) 3
32 (18160552) 4
24 (21680652) 4
MRI head without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 2 1 3 6 3
References Study Quality
36 (27017020) 4
35 (24766291) 2
17 (24529619) 3
34 (23966248) 4
33 (22766676) 3
38 (21439575) 3
37 (24485928) 3
39 (18765144) 4
30 (2022972) 4
31 (9051039) 3
32 (18160552) 4
24 (21680652) 4
MRA head without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 5 5 0 2 0 5 6 1 1 0 0
MRV head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 2 1 4 7 1 0 0 0
References Study Quality
43 (22723059) 2
40 (-3101268) 3
41 (23176141) 3
42 (17416816) 4
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 0 6 4 3 2 0 0
CTA head with IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 0 3 3 3 6 0 0 0 0
CTV head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 2 2 7 2 1 0 0 0
References Study Quality
25 (17494676) 3
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 13 0 1 0 1 0 0 0 0
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 3 5 1 3 2 1 0 0 0
MRV head with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 3 3 2 3 4 0 0 0 0
References Study Quality
43 (22723059) 2
40 (-3101268) 3
41 (23176141) 3
42 (17416816) 4
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 2 2 7 2 3 1 1 1 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 9 1 1 3 0 0 1 0 0
Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRA head without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 4 0 5 3 1
References Study Quality
26 (20541105) 4
21 (19164800) 4
MRI head without IV contrast Usually appropriate Limited O 0 mSv O 0 mSv [ped] 7 7 0 0 1 1 3 2 3 3 2
References Study Quality
39 (18765144) 4
45 (17898186) 4
44 (18372410) 4
48 (20935079) M
46 (21183489) 4
47 (20970274) 3
49 (11160469) 3
21 (19164800) 4
CT head without IV contrast Usually appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 8 8 0 0 0 0 0 0 1 7 7
References Study Quality
50 (26797666) M
CTA head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 2 5 0 5 2 0
References Study Quality
44 (18372410) 4
48 (20935079) M
21 (19164800) 4
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Arteriography cerebral Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 4 3 2 0 1 1 0 0
References Study Quality
45 (17898186) 4
46 (21183489) 4
47 (20970274) 3
MRI head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 3 3 1 2 5 3 3 1 0 0 0
References Study Quality
45 (17898186) 4
44 (18372410) 4
48 (20935079) M
46 (21183489) 4
47 (20970274) 3
49 (11160469) 3
21 (19164800) 4
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 2 5 2 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 3 3 3 3 3 2 3 0 1 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 6 1 5 1 0 0 2 0 0
References Study Quality
50 (26797666) M
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 5 0 5 1 2 1 1 0 0
References Study Quality
50 (26797666) M
CTV head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 1 4 5 1 0 1 0 0
Variant 4: Child. Headache attributed to infection. 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 Limited O 0 mSv O 0 mSv [ped] 8 8 0 0 0 1 0 0 2 5 7
References Study Quality
51 (20709770) 4
1 (19564257) 4
52 (25846458) 2
MRA head without IV contrast May be appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 4 4 0 1 2 6 6 0 0 0 0
MRI head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 0 3 3 4 3 2 0 0 0
References Study Quality
51 (20709770) 4
1 (19564257) 4
52 (25846458) 2
MRV head with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 4 4 2 3 1 3 5 1 0 0 0
References Study Quality
53 (20112042) 4
MRV head without IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 2 2 1 8 2 0 0 0
References Study Quality
53 (20112042) 4
CT head with IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 6 0 0 1 0 3 8 3 0 0
References Study Quality
52 (25846458) 2
CT head without IV contrast May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 1 0 4 9 0 1 0 0
References Study Quality
52 (25846458) 2
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 15 0 0 0 0 0 0 0 0
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 2 0 0 0 0 0 0
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 6 2 2 2 2 0 1 0 0
References Study Quality
52 (25846458) 2
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 3 3 3 3 3 2 3 1 0 0 0
CTV head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 2 6 3 2 1 1 0 0 0
Variant 5: Child. Headache attributed to remote trauma. 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] 8 8 0 0 0 1 3 1 1 8 1
References Study Quality
54 (18422678) 4
Radiography skull Usually not appropriate Expert Consensus ☢ <0.1 mSv ☢☢ 0.03-0.3 mSv [ped] 1 1 12 1 1 1 0 0 0 0 0
Arteriography cerebral Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 12 2 0 1 0 0 0 0 0
MRA head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 5 4 3 2 0 1 0 0 0
MRI head without and with IV contrast Usually not appropriate Limited O 0 mSv O 0 mSv [ped] 2 2 5 4 2 1 1 2 0 0 0
References Study Quality
54 (18422678) 4
MRV head with IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 7 6 1 1 0 0 0 0 0
MRV head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 2 2 6 5 2 0 2 0 0 0 0
CT head with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 8 3 1 0 1 1 1 0 0
References Study Quality
55 (25647678) 3
CT head without and with IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 2 1 1 2 1 0 0 0
References Study Quality
55 (25647678) 3
CT head without IV contrast Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 3 3 2 4 3 5 0 1 0 0 0
References Study Quality
55 (25647678) 3
CTA head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 4 5 2 3 1 0 0 0 0
CTV head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 2 2 7 6 1 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.