Demyelinating Diseases

Variant: 1 Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI cervical and thoracic spine without and with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MRI cervical and thoracic spine with IV contrast	May Be Appropriate	O
MRI cervical and thoracic spine without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI lumbar spine without and with IV contrast	May Be Appropriate	O
MRI orbits with IV contrast	May Be Appropriate	O
MRI orbits without and with IV contrast	May Be Appropriate	O
MRI orbits without IV contrast	May Be Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT cervical and thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI cervical and thoracic spine without and with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MRI cervical and thoracic spine with IV contrast	May Be Appropriate	O
MRI cervical and thoracic spine without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI lumbar spine without and with IV contrast	May Be Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without IV contrast	Usually Not Appropriate	O
MRI orbits with IV contrast	Usually Not Appropriate	O
MRI orbits without and with IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT cervical and thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI cervical and thoracic spine without and with IV contrast	Usually Appropriate	O
MRI cervical and thoracic 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
MRI cervical and thoracic spine with IV contrast	May Be Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without and with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without IV contrast	Usually Not Appropriate	O
MRI orbits with IV contrast	Usually Not Appropriate	O
MRI orbits without and with IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT cervical and thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI cervical and thoracic spine without and with IV contrast	Usually Appropriate	O
MRI head without and with IV contrast	Usually Appropriate	O
MRI orbits without and with IV contrast	Usually Appropriate	O
MRI cervical and thoracic spine with IV contrast	May Be Appropriate	O
MRI cervical and thoracic spine without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRI orbits with IV contrast	May Be Appropriate (Disagreement)	O
MRI orbits without IV contrast	May Be Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without and with IV contrast	Usually Not Appropriate	O
MRI lumbar spine without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT cervical and thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI brachial plexus without and with IV contrast	Usually Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Appropriate	O
MRI lumbar spine without and with IV contrast	Usually Appropriate	O
MRI lumbosacral plexus without and with IV contrast	Usually Appropriate	O
MRI brachial plexus without IV contrast	May Be Appropriate (Disagreement)	O
MRI cervical and thoracic spine without IV contrast	May Be Appropriate	O
MRI head without and with IV contrast	May Be Appropriate	O
MRI lumbar spine without IV contrast	May Be Appropriate (Disagreement)	O
MRI lumbosacral plexus with IV contrast	May Be Appropriate	O
MRI lumbosacral plexus without IV contrast	May Be Appropriate (Disagreement)	O
MRI brachial plexus with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRI lumbar spine with IV contrast	Usually Not Appropriate	O
MRI orbits with IV contrast	Usually Not Appropriate	O
MRI orbits without and with IV contrast	Usually Not Appropriate	O
MRI orbits without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine with IV contrast	Usually Not Appropriate	☢☢☢
CT lumbar spine without IV contrast	Usually Not Appropriate	☢☢☢
CT orbits with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without and with IV contrast	Usually Not Appropriate	☢☢☢
CT orbits without IV contrast	Usually Not Appropriate	☢☢☢
CT cervical and thoracic spine with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT cervical and thoracic spine without IV contrast	Usually Not Appropriate	☢☢☢☢
CT lumbar spine without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Aleks Kalnins, MD, MBA^a; Lenora M. Lewis, MD^b; Karl A. Soderlund, MD^c; Matthew J. Austin, MD^d; Sammy Chu, MD^e; Dan B. Hawley, MD^f; Marinos Kontzialis, MD^g; Michael Levy, MD, PhD^h; John McMenamy, MDⁱ; Joan B. Ritter, MD^j; Ashesh A. Thaker, MD^k; Robert Y. Shih, MD^l.

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)

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. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
A. CT cervical and thoracic spine with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
B. CT cervical and thoracic spine without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
C. CT cervical and thoracic spine without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
D. CT head with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
E. CT head without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
F. CT head without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
G. CT lumbar spine with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
H. CT lumbar spine without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
I. CT lumbar spine without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
J. CT orbits with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
K. CT orbits without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
L. CT orbits without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
M. MRI cervical and thoracic spine with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
N. MRI cervical and thoracic spine without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
O. MRI cervical and thoracic spine without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
P. MRI head with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
Q. MRI head without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
R. MRI head without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
S. MRI lumbar spine with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
T. MRI lumbar spine without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
U. MRI lumbar spine without IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
V. MRI orbits with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
W. MRI orbits without and with IV contrast

Variant 1:Adult. Acute or subacute sensorimotor or brainstem symptoms. Suspect demyelinating disease of the central nervous system. Initial imaging.
X. MRI orbits without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
A. CT cervical and thoracic spine with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
B. CT cervical and thoracic spine without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
C. CT cervical and thoracic spine without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
D. CT head with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
E. CT head without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
F. CT head without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
G. CT lumbar spine with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
H. CT lumbar spine without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
I. CT lumbar spine without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
J. CT orbits with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
K. CT orbits without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
L. CT orbits without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
M. MRI cervical and thoracic spine with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
N. MRI cervical and thoracic spine without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
O. MRI cervical and thoracic spine without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
P. MRI head with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
Q. MRI head without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
R. MRI head without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
S. MRI lumbar spine with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
T. MRI lumbar spine without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
U. MRI lumbar spine without IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
V. MRI orbits with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
W. MRI orbits without and with IV contrast

Variant 2:Adult. Acute or subacute sensorimotor symptoms below a spinal cord level. Suspect transverse myelitis. Initial imaging.
X. MRI orbits without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
A. CT cervical and thoracic spine with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
B. CT cervical and thoracic spine without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
C. CT cervical and thoracic spine without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
D. CT head with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
E. CT head without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
F. CT head without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
G. CT lumbar spine with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
H. CT lumbar spine without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
I. CT lumbar spine without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
J. CT orbits with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
K. CT orbits without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
L. CT orbits without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
M. MRI cervical and thoracic spine with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
N. MRI cervical and thoracic spine without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
O. MRI cervical and thoracic spine without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
P. MRI head with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
Q. MRI head without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
R. MRI head without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
S. MRI lumbar spine with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
T. MRI lumbar spine without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
U. MRI lumbar spine without IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
V. MRI orbits with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
W. MRI orbits without and with IV contrast

Variant 3:Adult. Known demyelinating disease. Stable neurologic examination. Surveillance imaging.
X. MRI orbits without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
A. CT cervical and thoracic spine with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
B. CT cervical and thoracic spine without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
C. CT cervical and thoracic spine without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
D. CT head with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
E. CT head without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
F. CT head without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
G. CT lumbar spine with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
H. CT lumbar spine without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
I. CT lumbar spine without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
J. CT orbits with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
K. CT orbits without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
L. CT orbits without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
M. MRI cervical and thoracic spine with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
N. MRI cervical and thoracic spine without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
O. MRI cervical and thoracic spine without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
P. MRI head with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
Q. MRI head without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
R. MRI head without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
S. MRI lumbar spine with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
T. MRI lumbar spine without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
U. MRI lumbar spine without IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
V. MRI orbits with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
W. MRI orbits without and with IV contrast

Variant 4:Adult. Known demyelinating disease. New or progressive neurologic deficits. Initial imaging.
X. MRI orbits without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
A. CT cervical and thoracic spine with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
B. CT cervical and thoracic spine without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
C. CT cervical and thoracic spine without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
D. CT head with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
E. CT head without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
F. CT head without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
G. CT lumbar spine with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
H. CT lumbar spine without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
I. CT lumbar spine without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
J. CT orbits with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
K. CT orbits without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
L. CT orbits without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
M. MRI brachial plexus with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
N. MRI brachial plexus without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
O. MRI brachial plexus without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
P. MRI cervical and thoracic spine with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
Q. MRI cervical and thoracic spine without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
R. MRI cervical and thoracic spine without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
S. MRI head with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
T. MRI head without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
U. MRI head without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
V. MRI lumbar spine with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
W. MRI lumbar spine without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
X. MRI lumbar spine without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
Y. MRI lumbosacral plexus with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
Z. MRI lumbosacral plexus without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
[. MRI lumbosacral plexus without IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
\. MRI orbits with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
]. MRI orbits without and with IV contrast

Variant 5:Adult. Acute or chronic symmetric weakness. Suspect demyelinating disease of the peripheral nervous system. Initial imaging.
^. MRI orbits without IV contrast

Summary of Highlights

Supporting Documents

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

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

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

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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.