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ACR Appropriateness Criteria Head Trauma-2015


ACR Appropriateness Criteria Head Trauma-2015

Any injury that results in trauma to the skull or brain can be classified as a head injury. The terms traumatic brain injury and head injury are often used interchangeably in  medical literature.Unlike a broken bone where trauma to the body is obvious, head trauma can sometimes be conspicuous or inconspicuous. In the case of an open head injury, the skull is cracked and broken by an object that makes contact with the brain. This leads to bleeding. Other obvious symptoms can be neurological in nature. The person may become sleepy, behave abnormally, lose consciousness, vomit, develop a severe headache, have mismatched pupil sizes, and/or be unable to move certain parts of the body.While these symptoms happen right after head injury occurs, many problems can develop later in life. Alzheimer’s disease, for example, is much more likely to develop in a person who has experienced a head injury.

In 2015, the American College of Radiology published the ACR Appropriateness Criteria® Head Trauma. Following are its  major Appropriateness Criteria

Clinical Condition: Head Trauma

Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate*Relative Radiation Level

Variant 1: Minor or mild acute closed head injury (GCS ≥13), imaging not indicated by NOC or CCHR or NEXUS-II clinical criteria (see Appendix 1 of the original guideline). Initial study.
Radiologic Procedure Rating Comments RRL*
CT head without contrast 2 . radioactiveradioactiveradioactive
MRI head without contrast 1 O
MRA head and neck without contrast 1 O
MRA head and neck without and with contrast 1 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
CTA head and neck with contrast 1 radioactiveradioactiveradioactive
MRI head without and with contrast 1 O
MRI head without contrast with DTI 1 O
CT head with contrast 1 radioactiveradioactiveradioactive
X-ray skull 1 radioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive

Variant 2: Minor or mild acute closed head injury (GCS ≥13), imaging indicated by NOC or CCHR or NEXUS-II clinical criteria (see Appendix 1 of the original guideline document). Initial study.

Radiologic Procedure Rating Comments RRL*
CT head without contrast 9 radioactiveradioactiveradioactive
MRI head without contrast 5 This procedure may be appropriate in the outpatient setting, but there was disagreement among panel members on the appropriateness rating as defined by the panel’s median rating. O
MRA head and neck without contrast 2 O
MRA head and neck without and with contrast 2 O
CTA head and neck with contrast 1 radioactiveradioactiveradioactive
MRI head without and with contrast 1 O
MRI head without contrast with DTI 1 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
CT head with contrast 1 radioactiveradioactiveradioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive
X-ray skull 1 radioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive

Variant 3: Moderate or severe acute closed head injury (GCS <13). Initial study.

Radiologic Procedure Rating Comments RRL*
CT head without contrast 9 radioactiveradioactiveradioactive
MRI head without contrast 2 O
CTA head and neck with contrast 2 radioactiveradioactiveradioactive
MRA head and neck without contrast 1 O
MRA head and neck without and with contrast 1 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
MRI head without and with contrast 1 O
MRI head without contrast with DTI 1 O
X-ray skull 1 radioactive
CT head with contrast 1 radioactiveradioactiveradioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive

Variant 4: Short-term follow-up imaging of acute traumatic brain injury. No neurologic deterioration.

Radiologic Procedure Rating Comments RRL*
CT head without contrast 5 This procedure can be used in patients with risk factors (see narrative below). radioactiveradioactiveradioactive
CTA head and neck with contrast 2 radioactiveradioactiveradioactive
MRI head without contrast 2 O
MRA head and neck without contrast 2 O
MRA head and neck without and with contrast 2 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
CT head with contrast 1 radioactiveradioactiveradioactive
MRI head without and with contrast 1 O
MRI head without contrast with DTI 1 O
X-ray skull 1 radioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive

Variant 5: Short-term follow-up imaging of acute traumatic brain injury. Neurologic deterioration, delayed recovery, or persistent unexplained deficits.

Radiologic Procedure Rating Comments RRL*
CT head without contrast 9 radioactiveradioactiveradioactive
MRI head without contrast 8 This procedure is complementary if CT does not explain clinical symptoms. O
CT head without and with contrast 5 This procedure can be used in patients with suspected post-traumatic infection. radioactiveradioactiveradioactive
CTA head and neck with contrast 5 See Variant 7 below. This procedure may be appropriate in patients with suspected post-traumatic infarction, but there was disagreement among panel members on the appropriateness rating as defined by the panel’s median rating. radioactiveradioactiveradioactive
MRI head without and with contrast 5 This procedure may be appropriate in patients with suspected post-traumatic infection, but there was disagreement among panel members on the appropriateness rating as defined by the panel’s median rating. O
MRA head and neck without contrast 5 See Variant 7 below. This procedure may be appropriate in patients with suspected post-traumatic infarction, but there was disagreement among panel members on the appropriateness rating as defined by the panel’s median rating. O
MRA head and neck without and with contrast 5 See Variant 7 below. This procedure may be appropriate in patients with suspected post-traumatic infarction, but there was disagreement among panel members on the appropriateness rating as defined by the panel’s median rating. O
CT head with contrast 4 This procedure can be used in patients with suspected post-traumatic infection. radioactiveradioactiveradioactive
MRI head without contrast with DTI 2 O
X-ray skull 1 radioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive

Variant 6: Subacute or chronic traumatic brain injury with new cognitive and/or neurologic deficit(s).

Radiologic Procedure Rating Comments RRL*
MRI head without contrast 9 O
CT head without contrast 7 This procedure is an alternative; it is usually the first-line procedure in rapidly evolving new neurologic deficits or if MRI is contraindicated. radioactiveradioactiveradioactive
MRA head and neck without contrast 3 O
MRA head and neck without and with contrast 3 O
FDG-PET/CT head 2 radioactiveradioactiveradioactiveradioactive
CTA head and neck with contrast 2 radioactiveradioactiveradioactive
MRI functional (fMRI) head without contrast 2 O
MR spectroscopy head without contrast 2 O
MRI head without and with contrast 1 O
MRI head without contrast with DTI 1 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
CT head with contrast 1 radioactiveradioactiveradioactive
X-ray skull 1 radioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive
*Relative Radiation Level

Variant 7: Suspected intra cranial arterial injury.

Radiologic Procedure Rating Comments RRL*
CTA head and neck with contrast 9 This procedure is an alternative; either CTA or MRA can be performed, depending on institutional preference. radioactiveradioactiveradioactive
MRA head and neck without and with contrast 9 This procedure is an alternative; either CTA or MRA can be performed, depending on institutional preference. O
MRI head without contrast 9 This procedure is complementary, in conjunction with MRA. O
CT head without contrast 9 This procedure is complementary, in conjunction with CTA. radioactiveradioactiveradioactive
MRA head and neck without contrast 7 This procedure is an alternative; either CTA or MRA can be performed, depending on institutional preference. O
Arteriography cervicocerebral 6 radioactiveradioactiveradioactive
MRI head without and with contrast 3 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
MRI head without contrast with DTI 1 O
CT head with contrast 1 radioactiveradioactiveradioactive
X-ray skull 1 radioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive

Variant 8: Suspected intra cranial venous injury.

Radiologic Procedure Rating Comments RRL*
CT venography head with contrast 9 This procedure is an alternative; either CTV or MRV can be performed, depending on institutional preference. radioactiveradioactiveradioactive
MR venography head without contrast 9 This procedure is an alternative; either CTV or MRV can be performed, depending on institutional preference. O
MR venography head without and with contrast 9 This procedure is an alternative; either CTV or MRV can be performed, depending on institutional preference. O
CT head without contrast 7 This procedure is complementary, in conjunction with CTV. radioactiveradioactiveradioactive
MRI head without and with contrast 6 O
Arteriography cervicocerebral 6 radioactiveradioactiveradioactive
MRI head without contrast 5 This procedure is complementary, in conjunction with MRV. This procedure may be appropriate but there was disagreement among panel members on the appropriateness rating as defined by the panel’s median rating. O
CT head without and with contrast 3 radioactiveradioactiveradioactive
CT head with contrast 2 radioactiveradioactiveradioactive
MRI head without contrast with DTI 1 O
X-ray skull 1 radioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive

Variant 9: Suspected post-traumatic cere brospinal fluid (CSF) leak.

Radiologic Procedure Rating Comments RRL*
CT maxillofacial without contrast 9 This procedure is an alternative in cases of suspected CSF rhinorrhea. radioactiveradioactiveradioactive
CT temporal bone without contrast 9 This procedure is an alternative in cases of suspected CSF otorrhea. radioactiveradioactiveradioactive
CT head cisternography with contrast 8 This procedure is complementary if CT maxillofacial or temporal bone is inconclusive. radioactiveradioactiveradioactive
In-111 DTPA cisternography 6 radioactiveradioactiveradioactive
MRI head without contrast 5 This procedure is used for suspected cephalocele. O
CT head without contrast 3 radioactiveradioactiveradioactive
MRI head without and with contrast 3 O
CT head without and with contrast 1 radioactiveradioactiveradioactive
CT head with contrast 1 radioactiveradioactiveradioactive
MRI head without contrast with DTI 1 O
X-ray skull 1 radioactive
FDG-PET/CT head 1 radioactiveradioactiveradioactiveradioactive
Tc-99m HMPAO SPECT head 1 radioactiveradioactiveradioactiveradioactive
Arteriography cervicocerebral 1 radioactiveradioactiveradioactive

To read the full guideline click on the following link:

https://acsearch.acr.org/docs/69481/Narrative/

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Geeta Sharma

Geeta Sharma

Studied at Carmel Convent School headed the sports wing of the school, was the General Secretary Miranda House Students/ Union,, Did journalism at Patriot and Eenadu/Newstime. worked as teacher warden in schools of Mussoorie/ Dehradun/ Noida
Source: American College of Radiology

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