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
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.