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American College of Radiology ACR Appropriateness Criteria®
Clinical Condition: Variant 1: Head Trauma Minor or mild acute closed head injury (GCS ≥13), without risk factors or neurologic deficit. Radiologic Procedure CT head without contrast MRI head without contrast MRA head and neck without contrast MRA head and neck without and with contrast CT head without and with contrast CTA head and neck with contrast MRI head without and with contrast CT head with contrast X-ray head FDG-PET/CT head US transcranial with Doppler Arteriography cervicocerebral Tc-99m HMPAO SPECT head Rating 7 4 3 3 3 3 2 1 1 1 1 1 1 Rarely indicated with mild trauma. Rarely indicated with mild trauma. Comments Known to have low yield. RRL* ☢☢☢ O O O ☢☢☢ ☢☢☢ O ☢☢☢ ☢ ☢☢☢☢ O ☢☢☢ ☢☢☢☢
*Relative Radiation Level
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
ACR Appropriateness Criteria®
3 Usually not appropriate.8. 7.” If vascular injury is suspected. If vascular injury is suspected.5. 4. O O O ☢☢☢ O ☢☢☢ ☢☢☢ ☢☢☢☢ ☢☢☢☢ O ☢ ☢☢☢ *Relative Radiation Level Rating Scale: 1. focal neurologic deficit. For problem solving. For problem solving.9 Usually appropriate ACR Appropriateness Criteria® 2 Head Trauma . For problem solving.2. and/or risk factors.6 May be appropriate. If vascular injury is suspected.Clinical Condition: Variant 2: Head Trauma Minor or mild acute closed head injury. Radiologic Procedure CT head without contrast MRI head without contrast MRA head and neck without contrast MRA head and neck without and with contrast CTA head and neck with contrast MRI head without and with contrast CT head without and with contrast CT head with contrast Tc-99m HMPAO SPECT head FDG-PET/CT head US transcranial with Doppler X-ray head Arteriography cervicocerebral Rating 9 6 5 5 5 3 2 1 1 1 1 1 1 Comments RRL* ☢☢☢ For problem solving. See statement regarding contrast in text under “Anticipated Exceptions.
9 Usually appropriate ACR Appropriateness Criteria® 3 Head Trauma .2. Radiologic Procedure CT head without contrast MRI head without contrast MRA head and neck without contrast MRA head and neck without and with contrast CTA head and neck with contrast CT head without and with contrast MRI head without and with contrast X-ray head CT head with contrast US transcranial with Doppler FDG-PET/CT head Arteriography cervicocerebral Tc-99m HMPAO SPECT head Rating 9 6 5 5 5 2 2 2 1 1 1 1 1 Comments RRL* ☢☢☢ O O See statement regarding contrast in text under “Anticipated Exceptions.” O ☢☢☢ ☢☢☢ O ☢ ☢☢☢ O ☢☢☢☢ ☢☢☢ ☢☢☢☢ *Relative Radiation Level Rating Scale: 1.8.Clinical Condition: Variant 3: Head Trauma Moderate or severe acute closed head injury.5. 4. 7.6 May be appropriate.3 Usually not appropriate.
3 Usually not appropriate.” If vascular abnormality is suspected. 4. RRL* ☢☢☢ O O O O ☢☢☢ ☢ ☢☢☢☢ ☢☢☢ ☢☢☢☢ ☢☢☢☢ O ☢☢☢☢ *Relative Radiation Level X-ray head 2 CT head without and with contrast CT head with contrast FDG-PET/CT head Tc-99m HMPAO SPECT head US transcranial with Doppler Arteriography cervicocerebral 2 1 1 1 1 1 Rating Scale: 1. If vascular abnormality is suspected.” If vascular abnormality is suspected.8. See statement regarding contrast in text under “Anticipated Exceptions.9 Usually appropriate ACR Appropriateness Criteria® 4 Head Trauma . Potentially useful in suspected nonaccidental trauma. Radiologic Procedure CT head without contrast MRI head without contrast MRI head without and with contrast MRA head and neck without contrast MRA head and neck without and with contrast CTA head and neck with contrast Rating 9 7 4 4 4 4 Comments Diffusion-weighted imaging is especially helpful for nonaccidental trauma. Appropriate as part of skeletal survey in suspected nonaccidental trauma. child <2 years old.5.2.6 May be appropriate.Clinical Condition: Variant 4: Head Trauma Mild or moderate acute closed head injury. May be appropriate when screening for patients suspected of having penetrating head trauma or foreign bodies. 7. See statement regarding contrast in text under “Anticipated Exceptions.
Clinical Condition: Variant 5: Head Trauma Subacute or chronic closed head injury with cognitive and/or neurologic deficit(s).” For selected cases. ☢☢☢☢ ☢☢☢☢ O O ☢☢☢ O ☢☢☢ ☢☢☢ ☢ O O ☢☢☢ *Relative Radiation Level Rating Scale: 1. 7.9 Usually appropriate ACR Appropriateness Criteria® 5 Head Trauma .6 May be appropriate.5. For selected cases. For selected cases. See statement regarding contrast in text under “Anticipated Exceptions. 4.3 Usually not appropriate. For selected cases.2.8. Radiologic Procedure MRI head without contrast CT head without contrast Tc-99m HMPAO SPECT head FDG-PET/CT head MRA head and neck without contrast MRA head and neck without and with contrast CTA head and neck with contrast MRI head without and with contrast CT head without and with contrast CT head with contrast X-ray head MRI functional (fMRI) head without contrast US transcranial with Doppler Arteriography cervicocerebral Rating 8 6 4 4 4 4 4 3 2 2 2 2 1 1 Comments RRL* O ☢☢☢ For selected cases.
6 May be appropriate. See statement regarding contrast in text under “Anticipated Exceptions.5.3 Usually not appropriate. See statement regarding contrast in text under “Anticipated Exceptions.9 Usually appropriate ACR Appropriateness Criteria® 6 Head Trauma .2.” Include diffusion-weighted images. ☢☢☢ ☢☢☢ O ☢☢☢ ☢ ☢☢☢☢ O ☢☢☢☢ *Relative Radiation Level Rating Scale: 1. Radiologic Procedure CTA head and neck with contrast MRA head and neck without contrast MRA head and neck without and with contrast MRI head without contrast CT head without contrast CT head without and with contrast Arteriography cervicocerebral MRI head without and with contrast CT head with contrast X-ray head Tc-99m HMPAO SPECT head US transcranial with Doppler FDG-PET/CT head Rating 8 8 8 8 8 6 6 6 4 2 1 1 1 Comments RRL* ☢☢☢ Add T1 neck images. 4. rule out carotid or vertebral artery dissection.8.” Consider perfusion.Clinical Condition: Variant 6: Head Trauma Closed head injury. 7. Add T1 neck images. O O O ☢☢☢ Consider perfusion. For problem solving.
8.2. If there is no MRI contraindication. Radiologic Procedure CT head without contrast CTA head and neck with contrast MRA head and neck without contrast MRA head and neck without and with contrast Arteriography cervicocerebral MRI head without contrast CT head without and with contrast MRI head without and with contrast X-ray head CT head with contrast US transcranial with Doppler Tc-99m HMPAO SPECT head FDG-PET/CT head Rating 9 7 6 6 5 5 4 4 4 2 1 1 1 Comments RRL* ☢☢☢ ☢☢☢ If there is no MRI contraindication.Clinical Condition: Variant 7: Head Trauma Penetrating injury. If there is no MRI contraindication. 7. See statement regarding contrast in text under “Anticipated Exceptions. stable. 4. Consider perfusion. If there is no MRI contraindication.6 May be appropriate.5.” If vascular injury is suspected. See statement regarding contrast in text under “Anticipated Exceptions.3 Usually not appropriate. neurologically intact.” O O ☢☢☢ O ☢☢☢ O ☢ ☢☢☢ O ☢☢☢☢ ☢☢☢☢ *Relative Radiation Level Rating Scale: 1.9 Usually appropriate ACR Appropriateness Criteria® 7 Head Trauma .
” O ☢☢☢ O ☢☢☢☢ ☢☢☢ ☢☢☢☢ *Relative Radiation Level Rating Scale: 1. ☢☢☢ O ☢ O ☢☢☢ O For selected cases.8.Clinical Condition: Variant 8: Head Trauma Skull fracture.2.” See statement regarding contrast in text under “Anticipated Exceptions.9 Usually appropriate ACR Appropriateness Criteria® 8 Head Trauma . Radiologic Procedure CT head without contrast CTA head and neck with contrast MRI head without contrast X-ray head MRI head without and with contrast CT head without and with contrast MRA head and neck without contrast MRA head and neck without and with contrast CT head with contrast US transcranial with Doppler Tc-99m HMPAO SPECT head Arteriography cervicocerebral FDG-PET/CT head Rating 9 7 6 5 4 4 4 4 2 1 1 1 1 Comments RRL* ☢☢☢ If vascular injury is suspected. See statement regarding contrast in text under “Anticipated Exceptions.6 May be appropriate. Useful if infection is suspected.5.3 Usually not appropriate. 7. 4.
California. 14 Duke University Medical Center. Bethesda. Chicago. midline shift. 12 Littleton Adventist Hospital. See the ACR Appropriateness Criteria® on “Suspected Spine Trauma” for details. 6 Chesapeake Medical Imaging. Maryland. MD13. subdural. Ashley H. the New Orleans Criteria  and the Canadian CT Head Rule  are clinical guidelines with high sensitivity for detecting injuries that require neurosurgical intervention. or epidural spaces). Durham. University of Cincinnati. MD12. penetrating injuries. CT limitations include insensitivity in detecting small and predominantly nonhemorrhagic lesions associated with trauma such as contusion. Patricia B.HEAD TRAUMA Expert Panel on Neurologic Imaging: Patricia C. MD3. Davis. Broderick. MD2. or a mechanism of injury that might result in spinal injury. 3 Panel Vice-chair. Cincinnati. For patients with minor head injury (Glasgow Coma Scale [GCS] score of 13-15). especially along bone surfaces that approximate the transverse plane of axial images [10-11]. Illinois. parenchymal. 2 Panel Chair. The effect of that study was to shift the focus of neuroimaging of head trauma away from skull radiography and toward recognition of intracranial pathology as demonstrated by CT scanning. 11 Dent Neurologic Institute. and acute hemorrhage regardless of location (ie. Maryland. Columbus. Raksin. 1891 Preston White Drive. MD14. Charles T. acute subdural hematoma) as well as those that require in-hospital observation and medical management . Sacramento. 5 University of Arkansas for Medical Sciences. cervical spine imaging is indicated for patients with head injury who have signs. Society of Nuclear Medicine. corpus callosum. MD11. and they offer a potential reduction in unnecessary CT scans [4-6]. Smirniotopoulos. and upper brainstem and cerebellum often go undetected on CT. Berger. Skull Radiography Masters et al  developed and prospectively tested a management strategy for selecting patients who may benefit from skull radiography following head trauma and offered recommendations for selecting patients who should receive CT scanning following head injury. Los Angeles. American Academy of Neurology. American Association of Neurological Surgeons/Congress of Neurological Surgeons. American Association of Neurological Surgeons/Congress of Neurological Surgeons. Angtuaco. Brian D. Waxman. ventricular size and configuration. Franz J. Atlanta. Reston. Cincinnati. Colorado. McConnell Jr. positron emission tomography (PET). 4 Emory Healthcare. Laszlo L. Nationwide Children’s Hospital. Potential risks of unnecessary exposure to ionizing radiation warrant judicious patient selection for CT scanning as well as radiation dose management . Computer-generated reformatted images may have value in detecting intracranial hemorrhages. 9 Head Trauma Summary of Literature Review Introduction/Background Craniocerebral injuries are a common cause of hospital admission following trauma. Rebecca S. Annette C. Jacksonville. Cornelius. Daniel F. 13 Rush University. Mechtler. Indiana. Georgia. and compatibility with other medical and life support devices. Seidenwurm. Single photon emission computed tomography (SPECT). Because cervical spine trauma may accompany a head injury. Roth. The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document. and are associated with significant long-term morbidity and mortality. MD17. Mallinckrodt Institute of Radiology. particularly in the adolescent and young adult populations. Douglas. Norfolk. Reprint requests to: Department of Quality & Safety. Little Rock. Computed tomography (CT) remains essential for detecting lesions that require immediate neurosurgical intervention (eg. symptoms. Wippold II. MD4. Aiken. Ohio. 18 Panel Chair (Pediatric Imaging). MD16. Northwest Radiology Consultants. Skull radiography is useful for imaging of calvarial fractures. and transcranial Doppler (TCD) have a complementary role in the assessment of nonacute brain injury. Christopher J. 8 Hampton Roads Radiology Associates. Alan D. Missouri. Arkansas. New York. North Carolina. As noted by Smits et al [7-8] all guidelines have a trade-off between sensitivity and specificity for detection of significant findings in head-injured patients.18 on CT. J. MD10. 16 Uniformed Services University. Computed Tomography CT’s advantages for evaluating the head-injured patient include its sensitivity for demonstrating mass effect. Ohio. Kevin L. Douglas C. subarachnoid. MD5. rapidity of scanning. 1 ACR Appropriateness Criteria® . MD7. or increased intracranial pressure. Indianapolis. Virginia. 10 Good Samaritan Hospital. California. American College of Radiology. Adair Prall. and in those who are neurologically impaired. MD1. 7 Mayo Clinic Jacksonville. VA 20191-4397. Annapolis. Edgardo J. David J. MD8. MD. Coley. There is now a general consensus that patients identified as having moderate or high risk for intracranial injury should undergo early postinjury noncontrast CT for evidence of intracerebral hematoma. 15 Radiological Associates of Sacramento. diffuse axonal injuries (DAIs) that result in small focal lesions throughout the cerebral hemispheres. James G. frontal lobes adjacent to the orbital roof and anterior temporal lobes adjacent to the greater sphenoid wing). Likewise. Brown. CT is relatively insensitive for detecting increased intracranial pressure or cerebral edema and for early demonstration of hypoxic-ischemic encephalopathy (HIE) that may accompany moderate or severe head injury. MD6. Saint Louis. MD9. and radiopaque foreign bodies. A number of clinical criteria similar to those of Masters et al  are used to predict patient risk categories for intracranial injury. Other imaging modalities such as magnetic resonance imaging (MRI) depict nonsurgical pathology not visible Principal Author. Florida. bone injuries. MD15. Amherst. Neuroimaging plays an essential role in identifying and characterizing these brain injuries. Georgia. Littleton. 9 Indiana University Hospital. 17 Cedars-Sinai Medical Center. Atlanta. Other advantages include its widespread availability. particularly when they are adjacent to bony surfaces (eg. Ohio.
Intracranial and neck MRA with fat-suppressed T1weighted neck MR are helpful for screening vascular lesions such as thromboses. fistulae. Vascular injuries typically occur with penetrating trauma (eg. drug or alcohol intoxication.There is an inverse relationship between declining clinical or neurologic status as described by the GCS  and the incidence and severity of CT abnormalities related to head injury [14-16]. or diagnosis and neurointerventional treatment of uncontrolled hemorrhage. Although CT triage of head-injured patients who require hospital admission offers a reduced burden on inpatient hospital services at lower cost than routine hospital admission for observation. two or more vomiting episodes. and high-impact injury mechanism . and MR Angiography Since the development of CT in the mid-1970s. Cerebral Angiography. basal skull fracture. gunshot wound or stabbing). or cerebral edema . appropriateness criteria for imaging of child abuse have already been described (see the pediatric sections of the ACR Appropriateness Criteria®). bicycle-related injury. fistulae. Rapid CT scanning is readily available in most hospitals that treat head-injured patients. In the minor head injury setting with a GCS score of 15. skull base. sensory deficit. or age ≥65 years. some cerebral aneurysm clips) or occult foreign bodies. Head Trauma . incompatibility with various medical and life support devices. and location of MR abnormalities in subacute head injury have been used to predict the recovery outcome of patients in a post-traumatic vegetative state . Dynamic spiral CT angiography (CTA) and magnetic resonance angiography (MRA) have a role as less invasive screening tools for detecting traumatic intracranial. Although experienced physicians can often predict the likelihood of an abnormal CT scan in moderate or severe head injury. MRI is very sensitive for detecting and characterizing subacute and chronic brain injuries. For pediatric patients. fracture lines approaching an artery. Cerebral infarction is an infrequent accompaniment of head injury. In part. particularly for children younger than age two [21-23]. CT Angiography. or dissection . A prospective trial of the Canadian CT Head Rule in Canadian emergency departments did not result in reduced rates of CT scanning in head trauma . age younger than 2 years. dissection. CTA of the aortic arch and neck vasculature may reveal carotid or vertebral dissection. pseudoaneurysms. although dissection and traumatic aneurysm may follow blunt or closed head trauma . MRI advances such as open-bore geometry. and patterns of infarction suggest that direct vascular compression related to intracranial mass lesions is the most common underlying mechanism . GCS score ≥13) who harbor significant intracranial pathology and/or require acute surgical intervention have been problematic. to detect delayed hematoma. or trauma to the neck [29-31]. Stiell et al  reported 100% sensitivity for detecting neurosurgical and/or clinically important brain injury in subjects with a GCS score of 1315 based on high-risk factors of failure to reach a GCS score of 15 within 2 hours. The number. size. these limitations can be overcome by situating MRI scanners close to emergency care areas with appropriate design and equipment for managing acutely injured patients [35-36]. While CT is sensitive for detecting injuries requiring a change in treatment . Magnetic Resonance Imaging MRI in imaging of head trauma is hindered by its limited availability in the acute trauma setting. Independent predictors for arterial vascular injury as depicted by craniocerebral CTA in blunt trauma include cervical facet subluxation/dislocation. and evidence of basilar skull fracture. MRI also is used for acute head-injured patients with nonsurgical. CT has a role in subacute or chronic head ACR Appropriateness Criteria® 10 injury for depicting atrophy. long imaging times. medically stable pathology. faster imaging sequences. vomiting. the result is greater CT use in the emergency setting [15. hypoxic-ischemic lesions. most cardiac pacemakers. Atabaki et al  reported 95. For this reason. and chronic subdural hematoma. sign of basal skull fracture.4% sensitivity for intracranial injury using factors. clinical selection criteria of patients with minor or mild injury (eg. Other factors include the need for MRI-specific monitoring equipment and ventilators. more liberal use of CT scanning has been suggested for pediatric patients. and/or seizure. Noncontrast head CT plays an essential role in the evaluation of children with suspected physical injury from child abuse. skull defect. physical findings of supraclavicular trauma. including dizziness. older than age 60. this must be balanced with the higher risk of radiation exposure in childhood via judicious patient selection for scanning as well as sized-based management of radiation dose [12. and improved patient monitoring equipment allow a greater role for MRI in closed head injuries. and the risk of scanning patients with certain indwelling devices (eg. Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration. thus the routine use of CT has been advocated as a screening tool to triage patients with minor or mild head injuries who require hospital admission or surgical intervention from those who can be safely discharged without hospital admission [17-19]. GSC score <15. On the other hand. and relative insensitivity to subarachnoid hemorrhage. and/or neck vascular lesions. hydrocephalus. sensitivity to patient motion. Cerebral angiography has a role in demonstrating and managing traumatic vascular injuries such as pseudoaneurysm. the New Orleans Criteria  found a 100% sensitivity for CT identification of an acute trauma lesion using risk factors of headache. Clinical criteria for scanning of children with head injury have been less reliable than those for adults. mental status change.24-26]. focal encephalomalacia. short-term memory deficit. the need for cerebral angiography for head injury has dramatically declined. suspected open skull fracture.17-19]. although angiography remains the gold standard for depicting dissection. especially in the first 72 hours after head injury.
perfusion MR. SPECT studies may reveal focal areas of hypoperfusion that are discordant with findings of MRI or CT [53-56]. blunt neck trauma. although its clinical role is uncertain given the disadvantages of radiation exposure and its limited area of brain coverage . Anticipated Exceptions Nephrogenic systemic fibrosis (NSF) is a disorder with a scleroderma-like presentation and a spectrum of manifestations that can range from limited clinical sequelae to fatality. MRA.44]. for detecting secondary effects of trauma such as edema and HIE. Oder et al  found that a pattern of global reduction of cerebral blood flow detected by SPECT predicted a poor likelihood of recovery for ACR Appropriateness Criteria® 11 patients who are in a persistent vegetative state due to head injury. In acute brain trauma. low velocity state. with lactate in areas of brain ischemia. It appears to be related to both Head Trauma . hypervolemia. perfusion MRI. Early and sometimes repeat CT scanning may be required if there is clinical and/or neurologic deterioration. so their use is generally limited to subacute or chronic patients. or edema [61-63]. A reduction in Nacetylaspartate (NAA)/creatine ratio and NAA on MRS may occur in areas of brain injury. Garnett et al  found that perfusion MRI may depict reduced blood volume in head-injured patients who do not show evidence of anatomic abnormalities on CT or MRI. and may have a role in prognosis. within 4 weeks) providing evidence of DAI following moderate to severe head trauma correlated with negative prognosis only in subjects with brain stem injury . Diffusion-weighted MRI and apparent diffusion coefficient (ADC) mapping depict cytotoxic injury almost immediately.45]. and/or skull base or cervical spine fracture. Diffusionweighted sequences improve detection of acute infarction associated with head injury.54]. as well as prognosis [44. perfusion CT. and 3) dorsal upper brain stem and cerebellum [41. especially in management of the acutely brain-injured patient. On the basis of these results. PET. Several investigators have suggested that TCD can be used to monitor early changes in blood flow velocities that may relate to vasospasm. particularly the splenium. Furthermore. SPECT and PET do not provide the anatomic detail or image resolution of CT or MRI for demonstrating acute or neurosurgical lesions of closed head injury. and for imaging DAI [41-43]. PET studies with fluorine-18labeled fluorodeoxyglucose (FDG) tracer may reveal more extensive abnormalities than CT or MRI . superior depiction of nonsurgical lesions with MRI may affect medical management and predict the degree of neurologic recovery [41. See the ACR Appropriateness Criteria® on “Suspected Spine Trauma” for details. Lang et al  found that the addition of gadolinium enhancement offered no significant advantage for lesion detection or characterization compared with noncontrast MRI images in head-injury patients. Fluid-attenuated inversion recovery (FLAIR) images are more sensitive than conventional MRI sequences for depicting subarachnoid hemorrhage and for lesions bordered by cerebrospinal fluid (CSF) . SPECT. Advanced imaging techniques (perfusion CT. DAI results from a shear-strain pattern of accelerationdeceleration with characteristic lesions in increasing order of injury severity in the: 1) cerebral white matter and gray-white matter junction. especially in the first 72 hours after injury. some investigators suggest that these functional imaging techniques may explain or predict postinjury neuropsychologic and cognitive deficits that are not explained by anatomic abnormalities detected by MRI or CT [51-52. TCD offers a noninvasive bedside evaluation of cerebral blood flow velocity and resistance in the major proximal vessels of the circle of Willis. Summary CT is the most appropriate initial study for acute evaluation of the head-injured patient who may harbor lesion(s) that require immediate neurosurgical intervention. Likewise. functional MRI. Functional Imaging Modalities Some reports suggest that there is a role for functional imaging techniques (SPECT. and PET) have utility in better understanding selected head-injured patients but are not considered routine clinical practice at this time. focal lesions demonstrated by SPECT offer objective evidence of organic injury in patients whose neuroimaging studies are otherwise normal . Although management of surgical injuries is not likely to be altered by the substitution of MRI for CT . The soft-tissue detail offered by MRI is superior to that of CT for depicting nonhemorrhagic primary lesions such as contusions.Hemosiderin-sensitive T2-weighted gradient echo and susceptibility-weighted sequences are helpful for imaging small or subacute or chronic hemorrhages. MRS limitations include limited anatomic coverage and lack of correlation of ratios with outcome in mild head injury at 6 months . Cervical spine imaging is often appropriate in headinjured patients. MRS) in assessing cognitive and neuropsychologic disturbances as well as recovery following head trauma [51-55].50]. and angiography) may depict traumatic vascular injuries in the setting of penetrating injury. 2) corpus callosum. Perfusion imaging with CT or MRI may prove helpful as a marker for disorders of vascular autoregulation or ischemia . Perfusion CT may likewise show abnormalities in cerebral blood flow after trauma that may correlate with outcome in mildly head-injured patients with disabling symptoms . Early MR imaging (ie. MR has a role in subacute or chronic injury for detecting and characterizing non-neurosurgical lesions such as HIE and DAI. Diffusion tensor imaging and MR spectroscopy (MRS) are ancillary tools that may offer additional insight into the biochemical and structural patterns of injury following head trauma. focal contusion and DAI may show restricted diffusion and evolve over time to atrophy or encephalomalacia [47-48]. Vascular imaging (CTA.
Livingston DH. The RRLs for these examinations are designated as “Varies”. 10. Wei SC. 57(1):14-17. 18. CMAJ 2010. Jennett B. JAMA 2005. 11. Radiology 2007.nci. There is growing literature regarding NSF. 245(3):831-838. both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). 182(14):1527-1532. Indications for computed tomography in patients with minor head injury. 17. Teasdale G. Vandemheen K.73m2). 33(3):385-394. and Joint Section on Neurotrauma and Critical Care of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. 19. Minor head injury: CT-based strategies for management--a cost-effectiveness analysis. Minor head injury: guidelines for the use of CT--a multicenter validation study. 4. Prospective optimization of patient selection for emergency cranial computed tomography: univariate and multivariate analyses. 21. Dippel DW. Wald SL. 20. et al. Luber S. J Trauma 1999. 8. Rothenberg BM. 20(12):1286-1289. Nguyen DT. 294(12):1519-1525.03 mSv 0. Reinus WR. 5. DeBlieux PM. de Haan GG. Zwemer FL. 357(9266):1391-1396. Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography? Ann Emerg Med 1993. Krosner SM. Stiell IG. please see the ACR Manual on Contrast Media . Radiology 2010. 2. Saul TG. because the actual patient doses in these procedures vary as a function of a number of factors (eg. rarely in patients with very limited glomerular filtration rate (GFR) (ie. Technical report: minor head injury in children. et al.3-3 mSv 3-10 mSv Supporting Document(s) ACR Appropriateness Criteria® Overview Procedure Information Evidence Table References 1. Fornoff JR.2002. Minimal head injury: is admission necessary? Am Surg 1991. N Engl J Med 1987. The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries. Henson JW. <30 mL/min/1. Dippel DW. http://www. Radiology 1992. August 20. Value of coronal reformations in the CT evaluation of acute head trauma. the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table below). Rowe BH. National Cancer Institute USNIoH. Loder PA. Assessment of coma and impaired consciousness. region of the body exposed to ionizing radiation. Wells GA. Arcarese JS. Smits M. Subtle pathology detection with multidetector row coronal and sagittal CT reformations in acute head trauma. Nagy KK. Dietrich AM. Ross SE. a relative radiation level (RRL) indication has been included for each imaging examination. A prospective clusterrandomized trial to implement the Canadian CT Head Rule in emergency departments. which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Skull x-ray examinations after head trauma.73m2. 7. 22(10):1535-1540. King DR. Patients in the pediatric age group are at inherently higher risk from exposure. Traumatic brain injuries: predictive usefulness of CT.underlying severe renal dysfunction and the administration of gadolinium-based contrast agents.. 182(3):777-781. et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. Although some controversy and lack of clarity remain. Grimshaw JM. 14. Invest Radiol 1996. Clement CM. Lancet 1974. J Trauma 1992. et al. Kosnik E. Clement CM. Relative Radiation Level Information Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. the imaging guidance that is used). Homer CJ. Gonzalez RG. Lev MH. AJNR 2010. Hamill RW. et al. Preston CA. Lancet 2001. Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document. Because there is a wide range of radiation exposures associated with different diagnostic procedures.3 mSv 0. et al. 9. Stiell IG. 343(2):100-105. Radiation risks and pediatric computed tomography (CT): a guide for health care providers. there is a consensus that it is advisable to avoid all gadolinium-based contrast agents in dialysis-dependent patients unless the possible benefits clearly outweigh the risk. O'Malley KF. 46(2):268-270. 1998. 104(6):e78. Clinical decision instruments for CT scanning in minor head injury. Bowman MJ. Smits M. JAMA 2005. 254(2):532-540. Kleinman L. Haydel MJ. 3. 31(2):101-108.03-0. Masters SJ. McClean PM.nih. Smits M. N Engl J Med 2000. Pomerantz SR. It has occurred primarily in patients on dialysis. Recommendations by a multidisciplinary panel and validation study. 294(12):1511-1518. Woolf PD. JAMA 2005. 30-100 mSv 10-30 mSv ☢☢☢☢☢ *RRL assignments for some of the examinations cannot be made. Mills TJ. Jr. et al. The RRLs are based on effective dose. Stiell IG.1 mSv 0. Pediatrics 1999.gov/cancertopics /causes/radiation-risks-pediatric-CT. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. Stein SC. and almost never in other patients. Shackford SR. 13. Cox C. de Haan GG. For these reasons. The Canadian CT Head Rule for patients with minor head injury. Nederkoorn PJ. Joseph KT. 294(12):1551-1553. Blaudeau E. Dippel DW. 15. 22. Is routine computed tomography scanning too expensive for mild head injury? Ann Emerg Med 1991. 316(2):84-91. 16. 12. et al. Emerg Radiol 2010. 17(2):97-102. Haydel MJ. Relative Radiation Level Designations Relative Radiation Level* O ☢ ☢☢ ☢☢☢ ☢☢☢☢ Adult Effective Dose Estimate Range 0 mSv <0. Ulmer S. Hunt CD. For more information. Ross SE. and to limit the type and amount in patients with estimated GFR rates <30 mL/min/1. 6. 2(7872):81-84. A practical scale.1-1 mSv 1-10 mSv 10-30 mSv Pediatric Effective Dose Estimate Range 0 mSv <0. et al. The utility of head computed tomography after minimal head injury. Managment of Head Injury. Ginn-Pease ME. 31(2):334-339. ACR Appropriateness Criteria® 12 Head Trauma . Kido DK. Zacharia TT.
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Only those examinations generally used for evaluation of the patient’s condition are ranked. study of new equipment and applications should be encouraged. Generally.The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). ACR Appropriateness Criteria® 14 Head Trauma . The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. These criteria are intended to guide radiologists. however. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.
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