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Imaging of Suspected Intracranial Hypotension
Variant: 1
Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI complete spine without and with IV contrast | Usually Appropriate | O |
| MRI complete spine without IV contrast | Usually Appropriate | O |
| MRI head without and with IV contrast | Usually Appropriate | O |
| MRI head without IV contrast | Usually Appropriate | O |
| CT myelography complete spine | May Be Appropriate | ☢☢☢☢☢ |
| Radiographic myelography digital subtraction complete spine | Usually Not Appropriate | ☢☢☢☢ |
| MR myelography complete spine | Usually Not Appropriate | O |
| MRI complete spine with IV contrast | Usually Not Appropriate | O |
| MRI head with IV contrast | Usually Not Appropriate | O |
| CT head cisternography | 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 | ☢☢☢ |
| DTPA cisternography | Usually Not Appropriate | ☢☢☢ |
| CT complete spine with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT myelography dynamic complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 2
Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Radiographic myelography digital subtraction complete spine | Usually Not Appropriate | ☢☢☢☢ |
| MR myelography complete spine | Usually Not Appropriate | O |
| MRI complete spine with IV contrast | Usually Not Appropriate | O |
| MRI complete spine without and with IV contrast | Usually Not Appropriate | O |
| MRI complete spine without 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 |
| MRI head without IV contrast | Usually Not Appropriate | O |
| CT head cisternography | 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 | ☢☢☢ |
| DTPA cisternography | Usually Not Appropriate | ☢☢☢ |
| CT complete spine with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT myelography complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
| CT myelography dynamic complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 3
Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Radiographic myelography digital subtraction complete spine | Usually Not Appropriate | ☢☢☢☢ |
| MR myelography complete spine | Usually Not Appropriate | O |
| MRI complete spine with IV contrast | Usually Not Appropriate | O |
| MRI complete spine without and with IV contrast | Usually Not Appropriate | O |
| MRI complete spine without 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 |
| MRI head without IV contrast | Usually Not Appropriate | O |
| CT head cisternography | 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 | ☢☢☢ |
| DTPA cisternography | Usually Not Appropriate | ☢☢☢ |
| CT complete spine with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT myelography complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
| CT myelography dynamic complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 4
Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
| Procedure | Appropriateness Category | Relative Radiation Level |
| MRI complete spine without and with IV contrast | Usually Appropriate | O |
| MRI complete spine without IV contrast | Usually Appropriate | O |
| CT myelography complete spine | May Be Appropriate | ☢☢☢☢☢ |
| Radiographic myelography digital subtraction complete spine | Usually Not Appropriate | ☢☢☢☢ |
| MR myelography complete spine | Usually Not Appropriate | O |
| MRI complete spine with IV contrast | Usually Not Appropriate | O |
| DTPA cisternography | Usually Not Appropriate | ☢☢☢ |
| CT complete spine with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT myelography dynamic complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
Variant: 5
Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Radiographic myelography digital subtraction complete spine | Usually Appropriate | ☢☢☢☢ |
| CT myelography dynamic complete spine | Usually Appropriate | ☢☢☢☢☢ |
| MR myelography complete spine | May Be Appropriate | O |
| DTPA cisternography | May Be Appropriate | ☢☢☢ |
| CT head cisternography | Usually Not Appropriate | ☢☢☢ |
Variant: 6
Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| Radiographic myelography digital subtraction complete spine | Usually Not Appropriate | ☢☢☢☢ |
| MR myelography complete spine | Usually Not Appropriate | O |
| MRI complete spine with IV contrast | Usually Not Appropriate | O |
| MRI complete spine without and with IV contrast | Usually Not Appropriate | O |
| MRI complete spine without 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 |
| MRI head without IV contrast | Usually Not Appropriate | O |
| CT head cisternography | 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 | ☢☢☢ |
| DTPA cisternography | Usually Not Appropriate | ☢☢☢ |
| CT complete spine with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without and with IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT complete spine without IV contrast | Usually Not Appropriate | ☢☢☢☢ |
| CT myelography complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
| CT myelography dynamic complete spine | Usually Not Appropriate | ☢☢☢☢☢ |
Panel Members
Vincent M. Timpone, MDa; Matthew S. Parsons, MDb; Daniel J. Boulter, MDc; Judah Burns, MDd; Rami W. Eldaya, MD, MBAe; Jonathan A. Grossberg, MDf; Alvand Hassankhani, MDg; Troy A. Hutchins, MDh; Adam G. Kelly, MDi; Majid A. Khan, MDj; A. Orlando Ortiz, MD, MBAk; Christopher A. Potter, MDl; Vinil N. Shah, MDm; Richard D. Shih, MDn; Chadwick L. Wright, MD, PhDo; Bruno Policeni, MD, MBAp.
Summary of Literature Review
Introduction/Background
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. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
A. CT complete spine with IV contrast
A. CT complete spine with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
B. CT complete spine without and with IV contrast
B. CT complete spine without and with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
C. CT complete spine without IV contrast
C. CT complete spine without IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
D. CT head cisternography
D. CT head cisternography
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
E. CT head with IV contrast
E. CT head with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
F. CT head without and with IV contrast
F. CT head without and with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
G. CT head without IV contrast
G. CT head without IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
H. CT myelography complete spine
H. CT myelography complete spine
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
I. CT myelography dynamic complete spine
I. CT myelography dynamic complete spine
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
J. DTPA cisternography
J. DTPA cisternography
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
K. MR myelography complete spine
K. MR myelography complete spine
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
L. MRI complete spine with IV contrast
L. MRI complete spine with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
M. MRI complete spine without and with IV contrast
M. MRI complete spine without and with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
N. MRI complete spine without IV contrast
N. MRI complete spine without IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
O. MRI head with IV contrast
O. MRI head with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
P. MRI head without and with IV contrast
P. MRI head without and with IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
Q. MRI head without IV contrast
Q. MRI head without IV contrast
Variant 1: Adult. Orthostatic headache from suspected intracranial hypotension, without recent spinal intervention that could cause CSF leakage. Initial imaging.
R. Radiographic myelography digital subtraction complete spine
R. Radiographic myelography digital subtraction complete spine
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
A. CT complete spine with IV contrast
A. CT complete spine with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
B. CT complete spine without and with IV contrast
B. CT complete spine without and with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
C. CT complete spine without IV contrast
C. CT complete spine without IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
D. CT head cisternography
D. CT head cisternography
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
E. CT head with IV contrast
E. CT head with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
F. CT head without and with IV contrast
F. CT head without and with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
G. CT head without IV contrast
G. CT head without IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
H. CT myelography complete spine
H. CT myelography complete spine
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
I. CT myelography dynamic complete spine
I. CT myelography dynamic complete spine
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
J. DTPA cisternography
J. DTPA cisternography
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
K. MR myelography complete spine
K. MR myelography complete spine
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
L. MRI complete spine with IV contrast
L. MRI complete spine with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
M. MRI complete spine without and with IV contrast
M. MRI complete spine without and with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
N. MRI complete spine without IV contrast
N. MRI complete spine without IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
O. MRI head with IV contrast
O. MRI head with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
P. MRI head without and with IV contrast
P. MRI head without and with IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Q. MRI head without IV contrast
Q. MRI head without IV contrast
Variant 2: Adult. Orthostatic headache from suspected intracranial hypotension within 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
R. Radiographic myelography digital subtraction complete spine
R. Radiographic myelography digital subtraction complete spine
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
A. CT complete spine with IV contrast
A. CT complete spine with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
B. CT complete spine without and with IV contrast
B. CT complete spine without and with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
C. CT complete spine without IV contrast
C. CT complete spine without IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
D. CT head cisternography
D. CT head cisternography
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
E. CT head with IV contrast
E. CT head with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
F. CT head without and with IV contrast
F. CT head without and with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
G. CT head without IV contrast
G. CT head without IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
H. CT myelography complete spine
H. CT myelography complete spine
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
I. CT myelography dynamic complete spine
I. CT myelography dynamic complete spine
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
J. DTPA cisternography
J. DTPA cisternography
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
K. MR myelography complete spine
K. MR myelography complete spine
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
L. MRI complete spine with IV contrast
L. MRI complete spine with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
M. MRI complete spine without and with IV contrast
M. MRI complete spine without and with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
N. MRI complete spine without IV contrast
N. MRI complete spine without IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
O. MRI head with IV contrast
O. MRI head with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
P. MRI head without and with IV contrast
P. MRI head without and with IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
Q. MRI head without IV contrast
Q. MRI head without IV contrast
Variant 3: Adult. Orthostatic headache from suspected intracranial hypotension without improvement post 72 hours of dural puncture or other spinal intervention that could cause CSF leakage. Initial imaging.
R. Radiographic myelography digital subtraction complete spine
R. Radiographic myelography digital subtraction complete spine
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
A. CT complete spine with IV contrast
A. CT complete spine with IV contrast
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
B. CT complete spine without and with IV contrast
B. CT complete spine without and with IV contrast
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
C. CT complete spine without IV contrast
C. CT complete spine without IV contrast
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
D. CT myelography complete spine
D. CT myelography complete spine
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
E. CT myelography dynamic complete spine
E. CT myelography dynamic complete spine
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
F. DTPA cisternography
F. DTPA cisternography
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
G. MR myelography complete spine
G. MR myelography complete spine
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
H. MRI complete spine with IV contrast
H. MRI complete spine with IV contrast
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
I. MRI complete spine without and with IV contrast
I. MRI complete spine without and with IV contrast
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
J. MRI complete spine without IV contrast
J. MRI complete spine without IV contrast
Variant 4: Adult. Obtundation with initial brain imaging features of suspected intracranial hypotension. Next imaging study.
K. Radiographic myelography digital subtraction complete spine
K. Radiographic myelography digital subtraction complete spine
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
A. CT head cisternography
A. CT head cisternography
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
B. CT myelography dynamic complete spine
B. CT myelography dynamic complete spine
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
C. DTPA cisternography
C. DTPA cisternography
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
D. MR myelography complete spine
D. MR myelography complete spine
Variant 5: Adult. Chronic daily headache from suspected intracranial hypotension with negative initial brain and spine imaging, but with history and clinical examination suggesting CSF leakage. Next imaging study.
E. Radiographic myelography digital subtraction complete spine
E. Radiographic myelography digital subtraction complete spine
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
A. CT complete spine with IV contrast
A. CT complete spine with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
B. CT complete spine without and with IV contrast
B. CT complete spine without and with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
C. CT complete spine without IV contrast
C. CT complete spine without IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
D. CT head cisternography
D. CT head cisternography
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
E. CT head with IV contrast
E. CT head with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
F. CT head without and with IV contrast
F. CT head without and with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
G. CT head without IV contrast
G. CT head without IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
H. CT myelography complete spine
H. CT myelography complete spine
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
I. CT myelography dynamic complete spine
I. CT myelography dynamic complete spine
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
J. DTPA cisternography
J. DTPA cisternography
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
K. MR myelography complete spine
K. MR myelography complete spine
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
L. MRI complete spine with IV contrast
L. MRI complete spine with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
M. MRI complete spine without and with IV contrast
M. MRI complete spine without and with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
N. MRI complete spine without IV contrast
N. MRI complete spine without IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
O. MRI head with IV contrast
O. MRI head with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
P. MRI head without and with IV contrast
P. MRI head without and with IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
Q. MRI head without IV contrast
Q. MRI head without IV contrast
Variant 6: Adult. Rebound headache following epidural blood patch or fibrin glue patch treatment for suspected intracranial hypotension. Initial imaging.
R. Radiographic myelography digital subtraction complete spine
R. Radiographic myelography digital subtraction complete spine
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.