Cerebrovascular Disease-Child

Variant: 1 Child age older than 6 months. Emergent imaging for clinical presentation suggestive of acute nonsickle–cell related stroke. New focal fixed or worsening neurologic defect lasting less than 24 hours from last seen normal state. No contraindications to emergent intervention. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
MRI head perfusion with IV contrast	May Be Appropriate	O
MRI head perfusion without IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
CTA head with IV contrast	May Be Appropriate	☢☢☢☢
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢☢
MRA head with IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head perfusion with IV contrast	Usually Not Appropriate
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
MRI head perfusion with IV contrast	May Be Appropriate	O
MRI head perfusion without IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
CTA head with IV contrast	May Be Appropriate	☢☢☢☢
US duplex Doppler transcranial	Usually Not Appropriate	O
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢☢
MRA head with IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head perfusion with IV contrast	Usually Not Appropriate
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
MRI head perfusion with IV contrast	May Be Appropriate	O
MRI head perfusion without IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
CT head without IV contrast	May Be Appropriate	☢☢☢
CTA head with IV contrast	May Be Appropriate	☢☢☢☢
US duplex Doppler transcranial	Usually Not Appropriate	O
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢☢
MRA head with IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head perfusion with IV contrast	Usually Not Appropriate
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
SPECT or SPECT/CT brain perfusion	Usually Not Appropriate	☢☢☢☢

Variant: 4 Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head and neck without IV contrast	Usually Appropriate	O
MRI head and neck without IV contrast	Usually Appropriate	O
CTA head and neck with IV contrast	Usually Appropriate	☢☢☢☢
Arteriography cervicocerebral	May Be Appropriate	☢☢☢☢
MRA head and neck with IV contrast	May Be Appropriate (Disagreement)	O
MRI head and neck with IV contrast	May Be Appropriate (Disagreement)	O
MRI head and neck without and with IV contrast	May Be Appropriate	O
CT head without IV contrast	May Be Appropriate	☢☢☢
US duplex Doppler transcranial and carotid artery	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CTA head with IV contrast	Usually Appropriate	☢☢☢☢
Arteriography cervicocerebral	May Be Appropriate	☢☢☢☢
MRA head with IV contrast	May Be Appropriate	O
MRI head with IV contrast	May Be Appropriate (Disagreement)	O
CT head without IV contrast	May Be Appropriate	☢☢☢
US duplex Doppler transcranial	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 6 Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Arteriography cervicocerebral	Usually Appropriate	☢☢☢☢
MRA head without IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
CTA head with IV contrast	Usually Appropriate	☢☢☢☢
MRA head with IV contrast	May Be Appropriate	O
MRI head with IV contrast	May Be Appropriate (Disagreement)	O
MRI head without IV contrast	May Be Appropriate (Disagreement)	O
US duplex Doppler transcranial	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	☢☢☢

Variant: 7 Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Arteriography cervicocerebral	Usually Appropriate	☢☢☢☢
MRA head without IV contrast	Usually Appropriate	O
CTA head with IV contrast	Usually Appropriate	☢☢☢☢
MRA head with IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
US duplex Doppler transcranial	Usually Not Appropriate	O
MRI head 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	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 8 Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
CTA head with IV contrast	Usually Appropriate	☢☢☢☢
Arteriography cervicocerebral	May Be Appropriate (Disagreement)	☢☢☢☢
MRA head with IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
US duplex Doppler transcranial	Usually Not Appropriate	O
MRI head 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	☢☢☢☢

Variant: 9 Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
MRA head without IV contrast	May Be Appropriate (Disagreement)	O
MRI head without and with IV contrast	May Be Appropriate	O
CTA head with IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
US duplex Doppler transcranial	Usually Not Appropriate	O
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢☢
MRA head with IV contrast	Usually Not Appropriate	O
MRI head 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	☢☢☢☢

Variant: 10 Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
MRV head with IV contrast	Usually Appropriate	O
MRV head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
CTV head with IV contrast	Usually Appropriate	☢☢☢☢
US duplex Doppler transcranial	Usually Not Appropriate	O
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢☢
MRI head 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	☢☢☢☢

Variant: 11 Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
US duplex Doppler transcranial	Usually Not Appropriate	O
Arteriography cervicocerebral	Usually Not Appropriate	☢☢☢☢
MRA head with IV contrast	Usually Not Appropriate	O
MRI head with 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	☢☢☢☢

Panel Members

Richard L. Robertson, MD^a; Susan Palasis, MD^b; Michael J. Rivkin, MD^c; Sumit Pruthi, MD, MBBS^d; Twyla B. Bartel, DO, MBA^e; Nilesh K. Desai, MD^f; Nadja Kadom, MD^g; Abhaya V. Kulkarni, MD^h; H.F. Samuel Lam, MD, MPHⁱ; Mohit Maheshwari, MD^j; Sarah S. Milla, MD^k; David M. Mirsky, MD^l; John S. Myseros, MD^m; Sonia Partap, MD, MSⁿ; Rupa Radhakrishnan, MD^o; Bruno P. Soares, MD^p; Andrew T. Trout, MD^q; Unni K. Udayasankar, MD^r; Matthew T. Whitehead, MD^s; Boaz Karmazyn, MD^t.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Child age older than 6 months. Emergent imaging for clinical presentation suggestive of acute nonsickle–cell related stroke. New focal fixed or worsening neurologic defect lasting less than 24 hours from last seen normal state. No contraindications to emergent intervention. Initial imaging.

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
A. CT Head

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
B. CTA Head

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
C. MRI Head

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
D. MRA Head

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
E. CT Head Perfusion

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
F. MR Head Perfusion

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
G. Arteriography Cervicocerebral

Variant 2: Child. Clinical presentation suggestive of acute stroke, not a candidate for emergent intervention. Initial imaging.
H. US Duplex Doppler Transcranial

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
A. CT Head

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
B. CTA Head

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
C. MRI Head

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
D. MRA Head

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
E. CT Head Perfusion

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
F. MR Head Perfusion

Variant 3: Child. Clinical presentation suggestive of acute stroke, known or suspected arteriopathy, or moyamoya. Not a candidate for emergent treatment. Initial imaging.
G. HMPAO SPECT or SPECT/CT Brain

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.
A. CT Head

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.
B. CTA Head and Neck

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.
C. MRI Head and Neck

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.
D. MRA Head and Neck

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.
E. Arteriography Cervicocerebral

Variant 4: Child. Known or suspected cervicocranial arterial dissection based on clinical or imaging findings. Next imaging study.
F. US Duplex Doppler Transcranial and Carotid Artery

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.
A. CT Head

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.
B. CTA Head

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.
C. MRI Head

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.
D. MRA Head

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.
E. Arteriography Cervicocerebral

Variant 5: Child. Clinical presentation suggestive of acute stroke, known or suspected central nervous system vasculitis. Initial imaging.
F. US Duplex Doppler Transcranial

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.
A. CT Head

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.
B. CTA Head

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.
C. MRI Head

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.
D. MRA Head

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.
E. Arteriography Cervicocerebral

Variant 6: Child. Nontraumatic intraparenchymal hemorrhage (hematoma) found on CT or MRI. Unknown etiology. Next imaging study.
F. US Duplex Doppler Transcranial

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.
A. CT Head

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.
B. CTA Head

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.
C. MRI Head

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.
D. MRA Head

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.
E. Arteriography Cervicocerebral

Variant 7: Child. Nontraumatic subarachnoid hemorrhage (SAH) detected by noncontrast CT. Next imaging study.
F. US Duplex Doppler Transcranial

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
A. CT Head

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
B. CTA Head

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
C. MRI Head

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
D. MRA Head

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
E. Arteriography Cervicocerebral

Variant 8: Child. Clinical presentation suggestive of acute stroke, known or suspected high-flow vascular anomaly. Initial imaging.
F. US Duplex Doppler Transcranial

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.
A. CT Head

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.
B. CTA Head

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.
C. MRI Head

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.
D. MRA Head

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.
E. Arteriography Cervicocerebral

Variant 9: Child. Clinical presentation suggestive of acute stroke, known or suspected low-flow vascular anomaly. Initial imaging.
F. US Duplex Doppler Transcranial

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.
A. CT Head

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.
B. CTV Head

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.
C. MRI Head

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.
D. MRV Head

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.
E. Arteriography Cervicocerebral

Variant 10: Child. Clinical presentation suggestive of acute stroke, known or suspected cortical vein or dural venous sinus thrombosis. Initial imaging.
F. US Duplex Doppler Transcranial

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.
A. CT Head

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.
B. CTA Head

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.
C. MRI Head

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.
D. MRA Head

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.
E. Arteriography Cervicocerebral

Variant 11: Child. Clinical presentation suggestive of acute stroke, sickle cell disease. New focal fixed or worsening neurologic defect. Initial imaging.
F. US Duplex Doppler Transcranial

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.”

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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.