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Appropriateness Criteria

Variant 1: Rapidly progressive dementia; suspected Creutzfeldt-Jakob disease. 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 Strong O 0 mSv O 0 mSv [ped] 8 8 0 0 0 0 0 0 7 2 6
References Study Quality
8 (16908558) 3
14 (15958503) 2
10 (13679271) 3
6 (20430851) 2
11 (22499277) 4
7 (19755520) 1
12 (15304574) 2
13 (17569970) 2
15 (15956529) 2
16 (25367029) 4
17 (27942451) 2
9 (28076012) 4
MRI head without IV contrast Usually appropriate Strong O 0 mSv O 0 mSv [ped] 8 8 0 1 0 0 1 1 1 4 6
References Study Quality
8 (16908558) 3
14 (15958503) 2
10 (13679271) 3
6 (20430851) 2
11 (22499277) 4
7 (19755520) 1
12 (15304574) 2
13 (17569970) 2
15 (15956529) 2
16 (25367029) 4
17 (27942451) 2
9 (28076012) 4
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 5 5 0 0 1 0 11 3 0 0 0
FDG-PET/CT brain May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 1 2 5 5 0 0 0 0
References Study Quality
4 (12483414) 2
5 (8414042) 4
SPECT or SPECT/CT brain perfusion May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 n/a 0 0 0 0 0 0 0 0 0
References Study Quality
18 (16769939) 4
19 (22050286) 3
SPECT or SPECT/CT brain perfusion May be appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 1 0 1 12 1 0 0 0 0
References Study Quality
18 (16769939) 4
19 (22050286) 3
MR spectroscopy head without IV contrast Usually not appropriate Strong O 0 mSv O 0 mSv [ped] 3 3 2 1 5 3 2 0 1 0 0
References Study Quality
6 (20430851) 2
7 (19755520) 1
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 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 7 3 2 1 0 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 8 3 0 0 1 1 1 0 0
Variant 2: Chorea; suspected Huntington disease. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 3 0 10
References Study Quality
22 (9040728) 4
23 (8929153) 2
24 (1531910) 2
25 (8418795) 4
26 (18096682) 2
27 (11889230) 2
28 (19646924) 2
MRI head without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 0 1 0 2 2 9 0 1 0
References Study Quality
22 (9040728) 4
23 (8929153) 2
24 (1531910) 2
25 (8418795) 4
26 (18096682) 2
27 (11889230) 2
28 (19646924) 2
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 1 0 1 11 1 1 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 0 0 0 1 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 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 11 0 2 0 0 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 11 0 0 2 0 1 0 0 0
FDG-PET/CT brain Usually not appropriate Limited ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 8 4 1 0 0 1 0 0 0
References Study Quality
21 (11696626) 2
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 1 0 0 1 0 0 0
Variant 3: Parkinsonian syndromes. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 0 0 3 3 7
References Study Quality
41 (19959017) 4
44 (16606907) 4
64 (15205125) 3
40 (12774211) 4
42 (12589575) 2
66 (24601752) 2
67 (17236991) 2
43 (10680806) 2
47 (12020268) 2
48 (9667563) 2
49 (8089667) 3
50 (15997415) 4
51 (12140668) 3
52 (11960896) 3
53 (17260343) 2
54 (10025428) 2
55 (11884785) 2
56 (20623769) 1
57 (17632713) 3
58 (15569735) 2
59 (8933868) 4
60 (19833793) 4
61 (12736089) 3
62 (15985570) 3
63 (15728291) 2
65 (7964700) 4
46 (29530959) 4
45 (24710392) 2
MRI head without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 2 3 3 4 1 0
References Study Quality
41 (19959017) 4
44 (16606907) 4
64 (15205125) 3
40 (12774211) 4
42 (12589575) 2
66 (24601752) 2
67 (17236991) 2
43 (10680806) 2
47 (12020268) 2
48 (9667563) 2
49 (8089667) 3
50 (15997415) 4
51 (12140668) 3
52 (11960896) 3
53 (17260343) 2
54 (10025428) 2
55 (11884785) 2
56 (20623769) 1
57 (17632713) 3
58 (15569735) 2
59 (8933868) 4
60 (19833793) 4
61 (12736089) 3
62 (15985570) 3
63 (15728291) 2
65 (7964700) 4
46 (29530959) 4
45 (24710392) 2
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 1 0 2 9 2 1 0 0 0
FDG-PET/CT brain May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 4 4 2 0 4 5 3 2 0 0 0
SPECT or SPECT/CT brain striatal May be appropriate ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 1 0 3 0 5 6 0 0 0
References Study Quality
37 (19959018) 4
33 (27489771) 3
34 (11199811) 4
35 (24773455) 4
36 (23515233) 3
38 (8489409) 3
39 (17764571) Good
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 1 1 0 0 0 1 0 0
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 0 0 0 1 0 0
Amyloid PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 0 0 0 1 1 0 0
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 1 0 0 1 1 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 0 0 1 0 1 1 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 3 0 0 0 0 1 0 0
Variant 4: Suspected neurodegeneration with brain iron accumulation. 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 1 0 0 0 0 2 2 9
References Study Quality
70 (12510040) 4
71 (21920862) 4
69 (16775270) 4
72 (18443312) 4
73 (15944911) 4
74 (19850762) 2
MRI head without and with IV contrast May be appropriate Limited O 0 mSv O 0 mSv [ped] 5 5 0 1 0 3 7 1 3 0 0
References Study Quality
70 (12510040) 4
71 (21920862) 4
69 (16775270) 4
72 (18443312) 4
73 (15944911) 4
74 (19850762) 2
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 0 1 10 3 1 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 0 0 0 0 0 1
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 11 2 0 0 0 0 0 0 1
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 11 0 1 0 0 1 1 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 1 1 0 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 2 0 0 0 0 1 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 1 0 0 0 0 0 1
Variant 5: Suspected motor neuron disease. 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 Strong O 0 mSv O 0 mSv [ped] 9 9 0 1 0 0 1 0 3 0 9
References Study Quality
76 (16324086) 4
77 (9344001) 3
78 (7997565) 2
79 (3382182) 4
80 (11412870) 2
81 (12084444) 2
82 (27995062) 2
83 (22529995) 1
84 (17296988) 2
85 (25971894) 4
MRI head without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 6 6 1 0 0 1 3 4 4 0 1
References Study Quality
76 (16324086) 4
77 (9344001) 3
78 (7997565) 2
79 (3382182) 4
80 (11412870) 2
81 (12084444) 2
82 (27995062) 2
83 (22529995) 1
84 (17296988) 2
85 (25971894) 4
MRI spine without and with IV contrast May be appropriate Strong O 0 mSv O 0 mSv [ped] 4 4 3 1 0 7 2 2 0 0 0
References Study Quality
89 (24847978) 4
90 (24219347) 2
91 (29122760) 3
88 (22435076) 4
87 (28586096) 2
86 (29379040) 2
MRI spine without IV contrast May be appropriate (Disagreement) Expert Opinion O 0 mSv O 0 mSv [ped] 5 5 1 0 1 1 3 7 0 1 1
References Study Quality
89 (24847978) 4
90 (24219347) 2
91 (29122760) 3
88 (22435076) 4
87 (28586096) 2
86 (29379040) 2
CT head without IV contrast May be appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 4 4 0 1 2 9 2 1 0 0 0
MR spectroscopy head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 1 0 0 1 0 0 1
MRI functional (fMRI) head without IV contrast Usually not appropriate Expert Consensus O 0 mSv O 0 mSv [ped] 1 1 10 1 1 1 0 0 0 0 1
CT head with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 1 1 10 0 2 0 0 2 0 0 0
CT head without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 11 1 0 0 0 1 1 0 0
CT spine with IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 12 0 0 0 1 0 1 0 0
CT spine without IV contrast Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv 1 1 10 0 1 1 1 0 0 1 0
FDG-PET/CT brain Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 0 0 0 1 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 n/a 0 0 0 0 0 0 0 0 0
SPECT or SPECT/CT brain perfusion Usually not appropriate Expert Consensus ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 1 1 10 2 1 0 0 0 0 0 1
CT spine without and with IV contrast Usually not appropriate Expert Consensus ☢☢☢☢ 10-30 mSv 1 1 11 0 1 0 1 0 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.