American College of Radiology
ACR Appropriateness Criteria®

Pre-Irradiation Evaluation and Management of Brain Metastases

Variant 1: 50-year-old patient with newly diagnosed cancer of any stage and new intracranial signs or symptoms.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head with standard dose IV contrast Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
CT head with IV contrast May be appropriate ☢☢☢ 1-10 mSv ☢☢☢ 0.3-3 mSv [ped] 6 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 50-year-old patient with newly diagnosed non-small-cell lung cancer with resectable primary and CT scan evidence of solitary brain metastasis.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI head with standard dose IV contrast Usually appropriate 9 n/a 0 0 0 0 0 0 0 0 0
MRI head with high dose contrast May be appropriate O 0 mSv 6 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 45-year-old patient with metastatic melanoma and newly diagnosed multiple small supratentorial brain metastases. On treatment with ipilimumab. Mild edema on imaging. No hydrocephalus, neurologic symptoms, or history of seizures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Corticosteroids 4-8 mg/day Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Corticosteroids 16 mg/day Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Anticonvulsants (prophylactic) Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 50-year-old patient with non–small-cell lung cancer and multiple supratentorial brain metastases. Mild edema on imaging. No hydrocephalus. Mild neurologic symptoms present. No history of seizures.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Corticosteroids 4-8 mg/day Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Corticosteroids 16 mg/day Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Anticonvulsants (prophylactic) Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 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.