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Cerebrovascular Diseases-Stroke and Stroke-Related Conditions

Variant: 1   Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
Procedure Appropriateness Category Relative Radiation Level
US duplex Doppler carotid artery 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 ☢☢☢
CTA neck with IV contrast Usually Appropriate ☢☢☢
MRA head without IV contrast May Be Appropriate O
MRA neck without and with IV contrast May Be Appropriate O
MRA neck without IV contrast May Be Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 2   Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without IV contrast Usually Appropriate O
CT head without IV contrast Usually Appropriate ☢☢☢
CTA head with IV contrast Usually Appropriate ☢☢☢
CTA neck with IV contrast Usually Appropriate ☢☢☢
US duplex Doppler carotid artery May Be Appropriate O
MRA head without IV contrast May Be Appropriate O
MRA neck without and with IV contrast May Be Appropriate O
MRA neck without IV contrast May Be Appropriate O
MRI head perfusion with IV contrast May Be Appropriate O
CT head perfusion with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV 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 ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 3   Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRA head without IV contrast Usually Appropriate O
MRA neck without and with 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 ☢☢☢
CTA neck with IV contrast Usually Appropriate ☢☢☢
US duplex Doppler carotid artery May Be Appropriate O
MRA neck without IV contrast May Be Appropriate O
MRI head perfusion with IV contrast May Be Appropriate O
CT head perfusion with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV 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 ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 4   Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without IV contrast Usually Appropriate O
CT head without IV contrast Usually Appropriate ☢☢☢
CTA head with IV contrast Usually Appropriate ☢☢☢
CTA neck with IV contrast Usually Appropriate ☢☢☢
US duplex Doppler carotid artery May Be Appropriate O
MRA head without IV contrast May Be Appropriate O
MRA neck without and with IV contrast May Be Appropriate O
MRA neck without IV contrast May Be Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 5   Adult. Prior ischemic infarct. Surveillance imaging.
Procedure Appropriateness Category Relative Radiation Level
CT head without IV contrast Usually Appropriate ☢☢☢
US duplex Doppler carotid artery May Be Appropriate O
MRA head without IV contrast May Be Appropriate (Disagreement) O
MRA neck without and with IV contrast May Be Appropriate (Disagreement) O
MRA neck without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate (Disagreement) O
CTA head with IV contrast May Be Appropriate ☢☢☢
CTA neck with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 6   Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with 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 ☢☢☢
MRA head without IV contrast May Be Appropriate O
MRV head without and with IV contrast May Be Appropriate O
MRV head without IV contrast May Be Appropriate O
CTV head with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler carotid artery Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion 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 ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢

Variant: 7   Adult. Suspected venous sinus thrombosis. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI head without IV contrast Usually Appropriate O
MRV head without and 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 ☢☢☢
CT head with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler carotid artery Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
CT head perfusion with IV contrast Usually Not Appropriate ☢☢☢
CT head without and with IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢

Variant: 8   Adult. Known venous sinus thrombosis. Surveillance imaging.
Procedure Appropriateness Category Relative Radiation Level
MRI head without and with IV contrast Usually Appropriate O
MRI head without IV contrast Usually Appropriate O
MRV head without and 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 carotid artery Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRA head without IV contrast Usually Not Appropriate O
MRA neck without and with IV contrast Usually Not Appropriate O
MRA neck without IV contrast Usually Not Appropriate O
MRI head perfusion 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 ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
CTA neck with IV contrast Usually Not Appropriate ☢☢☢

Variant: 9   Adult. Asymptomatic cervical bruit. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US duplex Doppler carotid artery Usually Appropriate O
MRA neck without and with IV contrast Usually Appropriate O
MRA neck without IV contrast Usually Appropriate O
CTA neck with IV contrast Usually Appropriate ☢☢☢
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral 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 perfusion with 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
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 10   Adult. Asymptomatic carotid stenosis. Surveillance imaging.
Procedure Appropriateness Category Relative Radiation Level
US duplex Doppler carotid artery Usually Appropriate O
MRA neck without and with IV contrast Usually Appropriate O
MRA neck without IV contrast Usually Appropriate O
CTA neck with IV contrast Usually Appropriate ☢☢☢
MRI head without IV contrast May Be Appropriate (Disagreement) O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral 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 perfusion with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTA head with IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 11   Adult. Suspected cervical vascular dissection or injury. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRA neck without and with IV contrast Usually Appropriate O
MRA neck without IV contrast Usually Appropriate O
CT head without IV contrast Usually Appropriate ☢☢☢
CTA neck with IV contrast Usually Appropriate ☢☢☢
MRA head without IV contrast May Be Appropriate O
MRI head without IV contrast May Be Appropriate O
CTA head with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler carotid artery Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
Arteriography cervicocerebral Usually Not Appropriate ☢☢☢
MRA head without and with IV contrast Usually Not Appropriate O
MRI head perfusion with IV contrast Usually Not Appropriate O
MRI head without and with IV contrast Usually Not Appropriate O
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Variant: 12   Adult. Known cervical vascular dissection or injury. Surveillance imaging.
Procedure Appropriateness Category Relative Radiation Level
MRA neck without and with IV contrast Usually Appropriate O
MRA neck without IV contrast Usually Appropriate O
CTA neck with IV contrast Usually Appropriate ☢☢☢
Arteriography cervicocerebral May Be Appropriate ☢☢☢
MRA head without IV contrast May Be Appropriate (Disagreement) O
CTA head with IV contrast May Be Appropriate ☢☢☢
US duplex Doppler carotid artery Usually Not Appropriate O
US duplex Doppler transcranial Usually Not Appropriate O
MRA head without and with IV contrast Usually Not Appropriate O
MRI head perfusion with 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
MRV head without and with IV contrast Usually Not Appropriate O
MRV head without 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 ☢☢☢
CT head without IV contrast Usually Not Appropriate ☢☢☢
CTV head with IV contrast Usually Not Appropriate ☢☢☢

Panel Members
Jeffrey S. Pannell, MDa; Amanda S. Corey, MDb; Robert Y. Shih, MDc; Matthew J. Austin, MDd; Sammy Chu, MDe; Melissa A. Davis, MD, MBAf; Andrew F. Ducruet, MDg; Christopher H. Hunt, MDh; Jana Ivanidze, MD, PhDi; Aleks Kalnins, MD, MBAj; Mary E. Lacy, MDk; Bruce M. Lo, MD, RDMS, MBAl; Gavin Setzen, MDm; Matthew D. Shaines, MDn; Bruno P. Soares, MDo; Karl A. Soderlund, MDp; Ashesh A. Thaker, MDq; Lily L. Wang, MBBS, MPHr; Judah Burns, MDs.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
A. Arteriography cervicocerebral
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
B. CT head perfusion with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
C. CT head with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
D. CT head without and with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
E. CT head without IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
F. CTA head with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
G. CTA neck with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
H. CTV head with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
I. MRA head without and with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
J. MRA head without IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
K. MRA neck without and with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
L. MRA neck without IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
M. MRI head perfusion with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
N. MRI head without and with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
O. MRI head without IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
P. MRV head without and with IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
Q. MRV head without IV contrast
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
R. US duplex Doppler carotid artery
Variant 1: Adult. Clinical transient ischemic attack (TIA). Symptoms resolved. Initial imaging
S. US duplex Doppler transcranial
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
A. Arteriography cervicocerebral
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
B. CT head perfusion with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
C. CT head with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
D. CT head without and with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
E. CT head without IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
F. CTA head with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
G. CTA neck with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
H. CTV head with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
I. MRA head without and with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
J. MRA head without IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
K. MRA neck without and with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
L. MRA neck without IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
M. MRI head perfusion with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
N. MRI head without and with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
O. MRI head without IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
P. MRV head without and with IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
Q. MRV head without IV contrast
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
R. US duplex Doppler carotid artery
Variant 2: Adult. Focal neurologic deficit. Clinically suspected acute ischemic stroke. Initial imaging.
S. US duplex Doppler transcranial
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
A. Arteriography cervicocerebral
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
B. CT head perfusion with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
C. CT head with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
D. CT head without and with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
E. CT head without IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
F. CTA head with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
G. CTA neck with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
H. CTV head with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
I. MRA head without and with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
J. MRA head without IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
K. MRA neck without and with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
L. MRA neck without IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
M. MRI head perfusion with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
N. MRI head without and with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
O. MRI head without IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
P. MRV head without and with IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
Q. MRV head without IV contrast
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
R. US duplex Doppler carotid artery
Variant 3: Adult. Recent ischemic infarct; less than 24 hours. Initial imaging.
S. US duplex Doppler transcranial
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
A. Arteriography cervicocerebral
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
B. CT head perfusion with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
C. CT head with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
D. CT head without and with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
E. CT head without IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
F. CTA head with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
G. CTA neck with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
H. CTV head with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
I. MRA head without and with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
J. MRA head without IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
K. MRA neck without and with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
L. MRA neck without IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
M. MRI head perfusion with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
N. MRI head without and with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
O. MRI head without IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
P. MRV head without and with IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
Q. MRV head without IV contrast
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
R. US duplex Doppler carotid artery
Variant 4: Adult. Recent ischemic infarct; greater than 24 hours. Initial imaging.
S. US duplex Doppler transcranial
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
A. Arteriography cervicocerebral
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
B. CT head perfusion with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
C. CT head with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
D. CT head without and with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
E. CT head without IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
F. CTA head with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
G. CTA neck with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
H. CTV head with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
I. MRA head without and with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
J. MRA head without IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
K. MRA neck without and with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
L. MRA neck without IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
M. MRI head perfusion with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
N. MRI head without and with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
O. MRI head without IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
P. MRV head without and with IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
Q. MRV head without IV contrast
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
R. US duplex Doppler carotid artery
Variant 5: Adult. Prior ischemic infarct. Surveillance imaging.
S. US duplex Doppler transcranial
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
A. Arteriography cervicocerebral
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
B. CT head perfusion with IV Contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
C. CT head with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
D. CT head without and with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
E. CT head without IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
F. CTA head with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
G. CTA neck with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
H. CTV head with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
I. MRA head without and with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
J. MRA head without IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
K. MRA neck without and with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
L. MRA neck without IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
M. MRI head perfusion with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
N. MRI head without and with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
O. MRI head without IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
P. MRV head without and with IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
Q. MRV head without IV contrast
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
R. US duplex Doppler carotid artery
Variant 6: Adult. Known intraparenchymal hemorrhage. No history of trauma. Follow-up imaging study.
S. US duplex Doppler transcranial
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
A. Arteriography cervicocerebral
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
B. CT head perfusion with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
C. CT head with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
D. CT head without and with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
E. CT head without IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
F. CTA head with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
G. CTA neck with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
H. CTV head with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
I. MRA head without and with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
J. MRA head without IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
K. MRA neck without and with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
L. MRA neck without IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
M. MRI head perfusion with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
N. MRI head without and with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
O. MRI head without IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
P. MRV head without and with IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
Q. MRV head without IV contrast
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
R. US duplex Doppler carotid artery
Variant 7: Adult. Suspected venous sinus thrombosis. Initial imaging.
S. US duplex Doppler transcranial
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
A. Arteriography cervicocerebral
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
B. CT head perfusion with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
C. CT head with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
D. CT head without and with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
E. CT head without IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
F. CTA head with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
G. CTA neck with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
H. CTV head with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
I. MRA head without and with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
J. MRA head without IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
K. MRA neck without and with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
L. MRA neck without IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
M. MRI head perfusion with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
N. MRI head without and with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
O. MRI head without IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
P. MRV head without and with IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
Q. MRV head without IV contrast
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
R. US duplex Doppler carotid artery
Variant 8: Adult. Known venous sinus thrombosis. Surveillance imaging.
S. US duplex Doppler transcranial
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
A. Arteriography cervicocerebral
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
B. CT head perfusion with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
C. CT head with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
D. CT head without and with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
E. CT head without IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
F. CTA head with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
G. CTA neck with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
H. CTV head with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
I. MRA head without and with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
J. MRA head without IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
K. MRA neck without and with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
L. MRA neck without IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
M. MRI head perfusion with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
N. MRI head without and with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
O. MRI head without IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
P. MRV head without and with IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
Q. MRV head without IV contrast
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
R. US duplex Doppler carotid artery
Variant 9: Adult. Asymptomatic cervical bruit. Initial imaging.
S. US duplex Doppler transcranial
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
A. Arteriography cervicocerebral
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
B. CT head perfusion with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
C. CT head with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
D. CT head without and with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
E. CT head without IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
F. CTA head with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
G. CTA neck with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
H. CTV head with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
I. MRA head without and with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
J. MRA head without IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
K. MRA neck without and with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
L. MRA neck without IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
M. MRI head perfusion with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
N. MRI head without and with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
O. MRI head without IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
P. MRV head without and with IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
Q. MRV head without IV contrast
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
R. US duplex Doppler carotid artery
Variant 10: Adult. Asymptomatic carotid stenosis. Surveillance imaging.
S. US duplex Doppler transcranial
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
A. Arteriography cervicocerebral
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
B. CT head perfusion with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
C. CT head with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
D. CT head without and with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
E. CT head without IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
F. CTA head with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
G. CTA neck with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
H. CTV head with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
I. MRA head without and with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
J. MRA head without IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
K. MRA neck without and with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
L. MRA neck without IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
M. MRI head perfusion with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
N. MRI head without and with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
O. MRI head without IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
P. MRV head without and with IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
Q. MRV head without IV contrast
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
R. US duplex Doppler carotid artery
Variant 11: Adult. Suspected cervical vascular dissection or injury. Initial imaging.
S. US duplex Doppler transcranial
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
A. Arteriography cervicocerebral
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
B. CT head perfusion with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
C. CT head with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
D. CT head without and with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
E. CT head without IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
F. CTA head with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
G. CTA neck with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
H. CTV head with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
I. MRA head without and with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
J. MRA head without IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
K. MRA neck without and with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
L. MRA neck without IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
M. MRI head perfusion with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
N. MRI head without and with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
O. MRI head without IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
P. MRV head without and with IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
Q. MRV head without IV contrast
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
R. US duplex Doppler carotid artery
Variant 12: Adult. Known cervical vascular dissection or injury. Surveillance imaging.
S. US duplex Doppler transcranial
Summary of Highlights
Acknowledgement
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.