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 | . | |
| 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 | ||
| CTA head and neck with contrast | 1 | ||
| MRI head without and with contrast | 1 | O | |
| MRI head without contrast with DTI | 1 | O | |
| CT head with contrast | 1 | ||
| X-ray skull | 1 | ||
| FDG-PET/CT head | 1 | ||
| Arteriography cervicocerebral | 1 | ||
| Tc-99m HMPAO SPECT head | 1 |
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 | ||
| 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 | ||
| MRI head without and with contrast | 1 | O | |
| MRI head without contrast with DTI | 1 | O | |
| CT head without and with contrast | 1 | ||
| CT head with contrast | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| FDG-PET/CT head | 1 | ||
| X-ray skull | 1 | ||
| Arteriography cervicocerebral | 1 |
Variant 3: Moderate or severe acute closed head injury (GCS <13). Initial study.
| Radiologic Procedure | Rating | Comments | RRL* |
|---|---|---|---|
| CT head without contrast | 9 | ||
| MRI head without contrast | 2 | O | |
| CTA head and neck with contrast | 2 | ||
| 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 | ||
| MRI head without and with contrast | 1 | O | |
| MRI head without contrast with DTI | 1 | O | |
| X-ray skull | 1 | ||
| CT head with contrast | 1 | ||
| FDG-PET/CT head | 1 | ||
| Arteriography cervicocerebral | 1 | ||
| Tc-99m HMPAO SPECT head | 1 |
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). | |
| CTA head and neck with contrast | 2 | ||
| 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 | ||
| CT head with contrast | 1 | ||
| MRI head without and with contrast | 1 | O | |
| MRI head without contrast with DTI | 1 | O | |
| X-ray skull | 1 | ||
| FDG-PET/CT head | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| Arteriography cervicocerebral | 1 |
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 | ||
| 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. | |
| 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. | |
| 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. | |
| MRI head without contrast with DTI | 2 | O | |
| X-ray skull | 1 | ||
| FDG-PET/CT head | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| Arteriography cervicocerebral | 1 |
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. | |
| MRA head and neck without contrast | 3 | O | |
| MRA head and neck without and with contrast | 3 | O | |
| FDG-PET/CT head | 2 | ||
| CTA head and neck with contrast | 2 | ||
| 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 | ||
| CT head with contrast | 1 | ||
| X-ray skull | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| Arteriography cervicocerebral | 1 | ||
| *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. | |
| 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. | |
| 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 | ||
| MRI head without and with contrast | 3 | O | |
| CT head without and with contrast | 1 | ||
| MRI head without contrast with DTI | 1 | O | |
| CT head with contrast | 1 | ||
| X-ray skull | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| FDG-PET/CT head | 1 |
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. | |
| 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. | |
| MRI head without and with contrast | 6 | O | |
| Arteriography cervicocerebral | 6 | ||
| 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 | ||
| CT head with contrast | 2 | ||
| MRI head without contrast with DTI | 1 | O | |
| X-ray skull | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| FDG-PET/CT head | 1 |
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. | |
| CT temporal bone without contrast | 9 | This procedure is an alternative in cases of suspected CSF otorrhea. | |
| CT head cisternography with contrast | 8 | This procedure is complementary if CT maxillofacial or temporal bone is inconclusive. | |
| In-111 DTPA cisternography | 6 | ||
| MRI head without contrast | 5 | This procedure is used for suspected cephalocele. | O |
| CT head without contrast | 3 | ||
| MRI head without and with contrast | 3 | O | |
| CT head without and with contrast | 1 | ||
| CT head with contrast | 1 | ||
| MRI head without contrast with DTI | 1 | O | |
| X-ray skull | 1 | ||
| FDG-PET/CT head | 1 | ||
| Tc-99m HMPAO SPECT head | 1 | ||
| Arteriography cervicocerebral | 1 |
To read the full guideline click on the following link:
https://acsearch.acr.org/docs/69481/Narrative/
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