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, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields. The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated. Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by those entities not providing these services is not authorized .
Revised 2010 (Resolution 12)*
ACR–ASNR PRACTICE GUIDELINE FOR THE PERFORMANCE OF COMPUTED TOMOGRAPHY (CT) OF THE BRAIN
PREAMBLE These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question. The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the physician or medical physicist in light of all the circumstances presented. Thus, an approach that differs from the guidelines, standing alone, does not necessarily imply that the approach was below the standard of care. To the contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in the guidelines when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology subsequent to publication of the guidelines. However, a practitioner who employs an approach substantially different from these guidelines is advised to document in the patient record information sufficient to explain the approach taken. The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment. Therefore, it should be recognized that adherence to these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient to deliver effective and safe medical care. The sole purpose of these guidelines is to assist practitioners in achieving this objective. I. INTRODUCTION
This guideline was developed collaboratively by the American College of Radiology (ACR) and the American Society of Neuroradiology (ASNR). Computed tomography (CT) is a technology extensively used in neuroradiology that produces cross-sectional displays using ionizing radiation to generate images resulting from X-ray absorption by the specific tissues examined. CT offers a high degree of utility in the examination of the brain. This guideline outlines the principles for performing high-quality CT imaging of the brain in pediatric and adult patients, including advanced applications such as CT perfusion, CT volumetry, CT angiography, and CT venography. II. INDICATIONS
Indications for CT of the brain include, but are not limited to: A. Primary Indications 1. Acute head trauma. 2. Suspected acute intracranial hemorrhage.
CT Brain / 1
9. Cortical dysplasia. 6. adopted in 2006) A. The written or electronic request for CT of the brain should provide sufficient information to demonstrate the medical necessity of the examination and allow for its proper performance and interpretation. 16. 11. Ataxia. Aneurysm evaluation. (See the ACR Practice Guideline for Communication of Diagnostic Imaging Findings. Congenital lesions (such as. Treated or untreated vascular lesions. and migration anomalies or other morphologic brain abnormalities. or multidetector multislice algorithm. exposure factors. craniosynostosis. Cranial nerve dysfunction. Increased intracranial pressure. Additional information regarding the specific reason for the examination or a provisional diagnosis would be helpful and may at times be needed to allow for the proper performance and interpretation of the examination. Drug toxicity. General Considerations Secondary Indications 1. 12.3. The accompanying clinical information should be provided by a physician or other appropriately licensed health care provider familiar with the patient’s clinical problem or question and consistent with the state’s scope of practice requirements. intracranial hemorrhage. 10. 11. Brain herniation. relevant patient history. Brain Imaging CT brain imaging may be performed with a sequential single-slice technique. Diplopia. collimation. or shunt revisions. QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL CT protocols for brain imaging should be designed to answer the specific clinical question. 18. window and center settings. Documentation that satisfies medical necessity includes 1) signs and symptoms and/or 2) relevant history (including known diagnoses). Suspected shunt malfunctions. B. 9. 8. see the ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with Ionizing Radiation. SPECIFICATIONS OF THE EXAMINATION The supervising physician must have complete understanding of the indications. or hemorrhagic lesions. Suspicion of neurodegenerative disease. risks. Vascular occlusive disease or vasculitis (including use of CT angiography and/or venography). Encephalitis. 10. 6. multislice helical (spiral) protocol. 17. The request for the examination must be originated by a physician or other appropriately licensed health care provider. Syncope. or if the supervising physician deems CT to be appropriate. When magnetic resonance imaging (MRI) imaging is unavailable or contraindicated. and image reconstruction algorithms. IV. Seizures. field of view. Evaluating psychiatric disorders. B. 5. 8.) The physician performing CT interpretation must have a clear understanding and knowledge of the anatomy and pathophysiology relevant to the examination. For CT of the brain. Acute neurologic deficits. and benefits of the examination. 13. 14. contiguous or overlapping axial slices should be acquired with a slice thickness of no greater than 5 mm. 3. 12. Suspected hydrocephalus. (ACR Resolution 35. Protocols should be reviewed and updated periodically to optimize the examination. 15. Detection or evaluation of calcification. 13. Neuroendocrine dysfunction. In the setting of trauma. Headache. 2 / CT Brain . Immediate postoperative evaluation following surgical treatment of tumor. slice spacing (table increment) or pitch. 4. and microcephaly). potential adverse reactions to contrast media. images should be obtained and/or reviewed at window settings appropriate for demonstrating brain and bone abnormalities as well as PRACTICE GUIDELINE See the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT). The physician should be familiar with relevant ancillary studies that the patient may have undergone. 2. 7. Mental status change. 4. For the pregnant or potentially pregnant patient. Developmental delay. slice intervals. as well as alternative imaging procedures. III. macrocephaly. Apnea. The supervising physician should be familiar with the indications for each examination. Suspected mass or tumor. 7. 5. but not limited to. Suspected intracranial infection.
CT volumetry. Cerebrospinal fluid (CSF) contrast administration requires use of nonionic agents approved for intrathecal use and should be performed with regard to applicable guidelines as outlined in the ACR–ASNR Practice Guideline for the Performance of Myelography and Cisternography. DOCUMENTATION 3. radiologic technologists. RADIATION SAFETY IN IMAGING Reporting should be in accordance with the ACR Practice Guideline for Communication of Diagnostic Imaging Findings. Scan times: per slice or image not more than 2 seconds. A written policy should be in place for dealing with emergencies such as cardiopulmonary arrest.. D. Limiting spatial resolution should be >10 lp/cm for a <24 cm display field of view (DFOV). in accordance with ALARA. while maintaining the necessary diagnostic image quality. Interscan delay: not more than 4 seconds (may be longer if intravascular contrast media is not used). including vital signs monitoring equipment. and patient support. The equipment. 6.. EQUIPMENT SPECIFICATIONS A. to vary examination protocols to take into account patient body habitus. manual techniques should be used to moderate the exposure while maintaining the necessary diagnostic 2. and staff members should be able to assist with procedures. The dose reduction devices that are available on imaging equipment should be active. or the images may be manipulated to allow selective visualization of specific tissues such as in CT perfusion. VI. For imaging of the cranial base. Advanced Applications In addition to directly acquired axial images. if not. cisternography) during imaging of the brain. V. cine-capable scanners are preferable with tube rotation ≤1 second and continuous cine imaging ≥60 seconds. Slice thickness: minimum slice thickness 2 mm or less. or CT venography. medications. For advanced applications (e.g. Radiologists. Radiologists. Intravenous contrast enhancement should be performed using appropriate injection protocols and in accordance with the ACR–SPR Practice Guideline for the Use of Intravascular Contrast Media. and to society as a whole. 5. CT angiography. or other more complex planes may be constructed from the axial data set to answer specific clinical questions. 4. Performance Standards To achieve acceptable clinical CT scans of the brain. Limiting spatial resolution: must be measured to verify that it meets the unit manufacturer’s specifications. support equipment. and all supervising physicians have a responsibility to minimize radiation dose to individual patients. Appropriate emergency equipment and medications must be immediately available to treat adverse reactions associated with administered medications.small subdural hematomas and soft tissue lesions (subdural windows). and other emergency support must also be appropriate for the range of ages or sizes in the patient populations. The equipment and medications should be monitored for inventory and drug expiration dates on a regular basis. VII. should have in place and should adhere to policies and procedures. an axial slice thickness as thin as possible. medical physicists.g. B. patient monitoring. This concept is known as “as low as reasonably achievable (ALARA). sagittal. Such applications are better performed with helical data sets using very thin slice thickness and overlapping reconstruction rather than routine axial sequential data. perfusion imaging or CTA). body mass index or lateral width. C. Contrast Studies Certain indications require administration of intravenous (IV) contrast media or intrathecal contrast (e. PRACTICE GUIDELINE CT Brain / 3 . See the ACR–ASNR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in Neuroradiologic Imaging.” Facilities. technologists. but no greater than 3 mm with spiral techniques and 2 mm with multidetector and nonspiral techniques. the CT scanner should meet or exceed the following specifications: 1. should be used for 2D reformatting or for 3D reconstruction. Patient monitoring equipment and facilities for cardiopulmonary resuscitation. such as height and/or weight. Table pitch: no greater than 2:1 for most CT scanners. See the ACR–ASNR Practice Guideline for the Performance of Computed Tomography (CT) Perfusion in Neuroradiologic Imaging. to staff. should be immediately available. in consultation with the medical physicist. reformatted images in coronal.
INFECTION CONTROL. MS. Commission ASNR Guidelines Committee Suresh K. 8:175-181. Pediatric AIDS: a longitudinal comparative MRI and CT brain imaging study. Chair. Infection Control. Chair Jacqueline A. Dolinskas. Depper. and safety should be developed and implemented in accordance with the ACR Policy on Quality Control and Improvement. MD. FACR Lawrence A. Fleishon. McDonald CT. Petrella. Lev MH. Equipment monitoring should be in accordance with the ACR–AAPM Technical Standard for Diagnostic Medical Physics Performance Monitoring of Computed Tomography (CT) Equipment. Munoz A. Pollina J. (ACR Resolution 17. MD John L. FACR 4 / CT Brain 2. MD Stephen A. MD R.4:63-80. FACR Sachin Gujar. Tarr. FACR Paul A. Radiology 2002. Meltzer. Jordan.org/guidelines) by the Guidelines and Standards Committee of the Commission on Neuroradiology in collaboration with the Subcommittee on Standards and Guidelines of the ASNR. FACR Stephen A. JD. QUALITY CONTROL AND IMPROVEMENT. MD Blaise V. Chair John D. Tanenbaum. SAFETY. MD Scott H.acr. 1988. radiation exposures should be measured and patient radiation doses estimated by a medical physicist in accordance with the appropriate ACR Technical Standard. Calzado A. For specific issues regarding CT quality control. FACR Christopher J. MD Robert W.222:227-236.: National Council on Radiation Protection (NCRP). Applegate. MD. MD Patrick A. FACR Howard B. et al.175:1361-1366. 16-. Md. MD Jacqueline A. Lev MH. Safety. CT perfusion scanning with deconvolution analysis: pilot study in patients with acute middle cerebral artery stroke. Barr. FACR Carol A. MD John E.org/guidelines). MD. FACR Jeffrey A. MD.acr. et al. see the ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT). Kassel. Stroke 2002. MD. Dolinskas. AND PATIENT EDUCATION Kavita K.. Kieffer. MD. et al. Nick Bryan. Rodriguez R. and Patient Education on the ACR web page (http://www. FACR. ACKNOWLEDGEMENTS This guideline was revised according to the process described under the heading The Process for Developing ACR Practice Guidelines and Technical Standards on the ACR web page (http://www. Bello. FACR Carolyn C. Patel M. Jordan. MD. patient education. MD. Mukherji. MD. Russell.33:959-966. Roth. FACR. Quality criteria implementation for brain and lumbar spine CT examinations. Eftimov L. PhD. Safety. FACR Edward J. Mukherji. FACR. Castillo M. J Child Neurol 1993. Larson. MD. infection control. FACR Mark H. AJR 2000. MD. Br J Radiol 2000. FACR Suresh K. MD. 6. CT angiography with whole brain perfused blood volume imaging: added clinical value in the assessment of acute stroke. MD. MBA. Quality Assurance for Diagnostic Imaging Equipment. FACR. PRACTICE GUIDELINE Policies and procedures related to quality. Infection Control. MD. Ertl-Wagner B. MD Edward E. MD Lawrence N. adopted in 2006 – revised in 2009. Bethesda. 3. 4-single-slice CT systems-comparison of image quality and posterior fossa artifacts in routine brain imaging with standard protocols.18:1720-1726. Cranial CT with 64-. Jordan. Kaye. 7. Principal Drafter: John E. Alberico RA. Thick-section reformatting of thinly collimated helical CT for reduction of skull baserelated artifacts. 8. . and Patient Education appearing under the heading Position Statement on QC & Improvement. Eur Radiol 2008. FACR Eric J. Chamberlain MC. MD. Stone. Eastwood JD. Resolution 11) VIII. MD. Loud P. Mukherji. Contrast enhancement in primary tumors of the brain and spinal cord. Turski. MPH. Ezzeddine MA. Liebscher. Chair Kimberly E. Raskin. Blume J. MD. MD John E. Jones. FACR Jeffrey R. MD Carol A. Klufas R. MD Alan D. Greco W. Jr. MD ACR Guidelines and Standards Committee Suresh K. Azhari T. FACR John E. MD. Kieffer. Neuroimaging Clin N Am 1994. MD. O’Brien. NCRP Report 99.73:384-395. MD. 5. Faro. 4. Bello. MMM. Rothman. Periodically. MD. Erickson. Jordan. MD Michael I. MD. FACR Comments Reconciliation Committee Michael M.image quality. Ulmer. FACR Suggested Reading (Additional articles that are not cited in the document but that the committee recommends for further reading on this topic) 1.
15. 12. Hollister LE. Jhaveri KS. Soyer P. 40.13:483-491. 35. Characterization by computed tomography. AJNR 1991.16:194-198. Levine LA.144:483-486.179:207-213. Computed tomography in the prediction of outcome in head injury. Endo Y. Gonzalez RG. 18. 39. 14. Bienkowski RS. 17.98:1326-1328. et al. Neuroimaging Clin N Am 1991. Gagne RM. Goldstein HA. Marshall SB. Comparison of clinical and neuroradiological findings in first-ever stroke. Matsumoto M. and venous sinuses. Jordan JE. Cardiovasc Ther 2009. Kaplan RT. Marks MP. Shapira A. Dose and pitch relationship for a particular multislice CT scanner. Prabhakar R. The value of brain imaging in children with headaches. Identification of pre. Mimouni M. Patel M. Kodama N. et al.96:413-416.224:353-360. Schaefer PW. 1986. Clin Radiol 2004. Pediatrics 1995.219:750-755. Neuroimaging of ischemic stroke with CT and MRI: advancing towards physiology-based diagnosis and therapy.15:1773-1778. Hope JK. 32. Napel S. 25.9 Suppl 1:S287-292. Enas GG. 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Radiology 1994.and postcentral gyri on CT and MR images on the basis of the medullary pattern of cerebral white matter. Haresh KP. Quint DJ. Standard and ultrafast MR imaging of the brain compared with cranial CT. 27. McCrohan JL. Saini S. Murayama K. AJR 2001. Choi SC. Jordan JE. Meyer FB. Stair-step artifacts with single versus multiple detector-row helical CT. Kashiwagi S. et al. et al.9. Neuroradiology of selected disorders of the meninges. Suzuki M. Radiology 2000. Goodsitt M. Kishimoto K. et al. CT and conventional and diffusion-weighted MR imaging in acute stroke: study in 691 patients at presentation to the emergency department. Atlas SW. Volumetric quantification of Fisher Grade 3 aneurysmal subarachnoid hemorrhage: a novel method to predict symptomatic vasospasm on admission computerized tomography scans. Kishore PR. Iwasaki S. Boutros N. Rudling O. Philadelphia. Lightfoote JB. Hoeffner EG. Imaging of closed head injury. J Natl Med Assoc 2006. Peterson B. 3D-CT arteriography and 3D-CT venography: the separate demonstration of arterial-phase and venous-phase on 3D-CT angiography in a single procedure. Rath GK.26:272-278. Goerss SJ. 13. Dynamic 3D-CT angiography. Radiology 2001.191:1-17. Domingues da Silva AA. Char DH. Clinical use of CT and MR scans in psychiatric patients. Stroke 1994. J Psychiatry Neurosci 1991. 41. J Neurosurg 2002. et al. Norrving B. Cranial CT of the unconscious adult patient. Average radiation doses in a standard head examination for 250 CT systems. 36. Patel MC. Evaluation of cerebral perfusion parameters measured by perfusion CT in chronic cerebral ischemia: comparison with xenon CT. Danziger Y. Orbital tumors in children. Wilkinson ID. 24. Jordan JE. Flodmark O. et al. Kodama N. Jayaraman MV. Threedimensional CT angiography in the detection and characterization of intracranial berry aneurysms. The diagnosis of head injury requires a classification based on computed axial tomography. A population-based study. Rubin GD. Acute neuromedical and neurosurgical admissions. Faerber E. Scatarige JC. Patterson JF. J Neurotrauma 1992. 29.7:29-48.62:404-415.17:439-445. 1:17-38. Wholebrain perfusion CT performed with a prototype 256detector row CT system: initial experience. Jones TR. Rubin GD. 21. Clin Radiol 2007. 38. Paik DS. Sorensen AG. 30. Nakane M.12:1213-1216. Cranial Computed Tomography in Infants and Children.59:690-698. Jordan MJ. Hakimelahi R. AJR 2001. Marshall LF. Joshi RC. Lindgren A. Cooper J. Fleischmann D. Comparison of computed tomography CT Brain / 5 PRACTICE GUIDELINE .97:401-407. Radiology 1987. Friedman JA. Sakuma J. Persistent enhancement after treatment for cerebral toxoplasmosis in patients with AIDS: predictive value for subsequent recurrence. Single. Development of a protocol for coronal reconstruction of the maxillofacial region from axial helical CT data.177:1273-1275. AJNR 2007. 25:1371-1377. Lallemand DP.28:299-304.26:635-641. 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