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Head Trauma-Child

Variant: 1   Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
Radiography skull Usually Not Appropriate ☢☢
Arteriography cerebral Usually Not Appropriate ☢☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
CT head without IV contrast May Be Appropriate ☢☢☢
Radiography skull Usually Not Appropriate ☢☢
Arteriography cerebral Usually Not Appropriate ☢☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 3   Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
CT head without IV contrast Usually Appropriate ☢☢☢
Radiography skull Usually Not Appropriate ☢☢
Arteriography cerebral Usually Not Appropriate ☢☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
Procedure Appropriateness Category Peds Relative Radiation Level
CT head without IV contrast Usually Appropriate ☢☢☢
Radiography skull Usually Not Appropriate ☢☢
Arteriography cerebral Usually Not Appropriate ☢☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRI head without IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 5   Child. Subacute blunt head trauma with cognitive or neurologic signs.
Procedure Appropriateness Category Peds Relative Radiation Level
MRI head without IV contrast Usually Appropriate O
CT head without IV contrast Usually Appropriate ☢☢☢
Radiography skull Usually Not Appropriate ☢☢
Arteriography cerebral Usually Not Appropriate ☢☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 6   Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
Procedure Appropriateness Category Peds Relative Radiation Level
MRI head without IV contrast Usually Appropriate O
MRA head without IV contrast May Be Appropriate (Disagreement) O
MRI head without and with IV contrast May Be Appropriate (Disagreement) O
MRI head without IV contrast with DTI May Be Appropriate (Disagreement) O
CT head without IV contrast May Be Appropriate (Disagreement) ☢☢☢
Radiography skull Usually Not Appropriate ☢☢
Arteriography cerebral Usually Not Appropriate ☢☢☢☢
MR spectroscopy head without IV contrast Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRI functional (fMRI) head without IV contrast Usually Not Appropriate O
CT head with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢☢
FDG-PET/CT brain Usually Not Appropriate ☢☢☢☢

Panel Members
Maura E. Ryan, MDa; Sumit Pruthi, MD, MBBSb; Nilesh K. Desai, MDc; Richard A. Falcone Jr., MD, MPHd; Orit A. Glenn, MDe; Madeline M. Joseph, MDf; Mohit Maheshwari, MDg; Jennifer R. Marin, MD, MSch; Catherine Mazzola, MDi; Sarah S. Milla, MDj; David M. Mirsky, MDk; John S. Myseros, MDl; Sumit N. Niogi, MD, PhDm; Sonia Partap, MD, MSn; Rupa Radhakrishnan, MDo; Richard L. Robertson, MDp; Bruno P. Soares, MDq; Unni K. Udayasankar, MDr; Matthew T. Whitehead, MDs; Jason N. Wright, MDt; Boaz Karmazyn, MDu.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Discussion of Procedures by Variant
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
A. Radiography skull
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
B. CT head with IV contrast
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
C. CTA head
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
D. MRI head
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
E. MRA head
Variant 1: Child. Minor acute blunt head trauma. Very low risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
F. Arteriography cerebral
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
A. Radiography skull
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
B. CT head
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
C. CTA head
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
D. MRI head
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
E. MRA head
Variant 2: Child. Minor acute blunt head trauma. Intermediate risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
F. Arteriography cerebral
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
A. Radiography skull
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
B. CT head
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
C. CTA head
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
D. MRI head
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
E. MRA head
Variant 3: Child. Minor acute blunt head trauma. High risk for clinically important brain injury per PECARN criteria. Excluding suspected abusive head trauma. Initial imaging.
F. Arteriography cerebral
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
A. Radiography skull
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
B. CT head 
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
C. CTA head
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
D. MRI head
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
E. MRA head
Variant 4: Child. Moderate or severe acute blunt head trauma (GCS less than or equal to 13). Excluding suspected abusive head trauma. Initial imaging.
F. Arteriography cerebral
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
A. Radiography skull
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
B. CT head 
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
C. CTA head
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
D. MRI head
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
E. MRA head
Variant 5: Child. Subacute blunt head trauma with cognitive or neurologic signs.
F. Arteriography cerebral
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
A. Radiography skull
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
B. CT head 
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
C. CTA head
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
D. MRI head
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
E. MRA head
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
F. Arteriography cerebral
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
G. FDG-PET/CT Brain
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
H. MR Spectroscopy Head
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
I. MRI Head without IV Contrast with DTI
Variant 6: Child. Chronic blunt head trauma with new or progressive cognitive or neurologic deficits. Excluding suspected abusive head trauma and post-traumatic seizure.
J. MRI functional (fMRI) head without IV contrast
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
References
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Disclaimer

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). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. 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.